California > Workers Comp > EAMS Forms
Application For Adjudication Of Claim WCAB 1 - California
| Application For Adjudication Of Claim Form. This is a California form and can be used in EAMS Forms Workers Comp . |
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STATE OF CALIFORNIA DIVISION OF WORKERS' COMPENSATION WORKERS' COMPENSATION APPEALS BOARD APPLICATION FOR ADJUDICATION OF CLAIM Amended Application Case No. SSN (Numbers Only) Venue choice is based upon (Completion of this section is required) County of residence of employee (Labor Code section 5501.5(a)(1) or (d).) County where injury occurred (Labor Code section 5501.5(a)(2) or (d).) County of principal place of business of employee's attorney (Labor Code section 5501.5(a)(3) or (d).) Select 3 - Letter Office Code For Place/Venue of Hearing (From the Document Cover Sheet) Injured Worker (Completion of this section is required) First Name MI Last Name Street Address/PO Box (Please leave blank spaces between numbers, names or words) Street Address2/PO Box (Please leave blank spaces between numbers, names or words) International Address (Please leave blank spaces between numbers, names or words) City Applicant (If other than Injured Worker) Insurance Carrier Employer State Zip Code Lien Claimant Name (Please leave blank spaces between numbers, names or words) Street Address/PO Box (Please leave blank spaces between numbers, names or words) Street Address2/PO Box (Please leave blank spaces between numbers, names or words) City DWC/WCAB Form 1A (11/2008) - (Page 1) State Zip Code WCAB1 Employer Information (Completion of this section is required) Insured Self-Insured Legally Uninsured Uninsured Employer Name (Please leave blank spaces between numbers, names or words) Employer Street Address/PO Box (Please leave blank spaces between numbers, names or words) City State Zip Code Insurance Carrier Information (If known and if applicable - include even if carrier is adjusted by claims administrator) Insurance Carrier Name (Please leave blank spaces between numbers, names or words) Insurance Carrier Street Address/PO Box (Please leave blank spaces between numbers, names or words) City State Zip Code Claims Administrator Information (If known and if applicable) Name (Please leave blank spaces between numbers, names or words) Street Address/PO Box (Please leave blank spaces between numbers, names or words) City State Zip Code IT IS CLAIMED THAT (Complete all relevant information): 1. The injured worker, born (DATE OF BIRTH: MM/DD/YYYY) , while employed as a(n) (OCCUPATION AT THE TIME OF INJURY) (Choose only one) specific injury suffered a : (Date of injury: MM/DD/YYYY) cumulative injury which began on (Start Date: MM/DD/YYYY) and ended on (End Date: MM/DD/YYYY) The injury occurred at Street Address/PO Box - Please leave blank spaces between numbers, names or words City DWC/WCAB Form 1A (11/2008) - (Page 2) , . State Zip Code WCAB1 (State which parts of the body were injured) Body Part 1: Body Part 2: Body Part 3: Body Part 4: Other Body Parts: 2. The injury occurred as follows: (EXPLAIN WHAT THE WORKER WAS DOING AT THE TIME OF INJURY AND HOW THE INJURY OCCURED) 3. Actual earnings at the time of injury: Rate of Pay $ Monthly Weekly Hourly State value of tips, meals, lodging, or other advantages, regularly received $ Monthly Weekly Hourly Number of hours worked per week 4. The injury caused disability as follows: Last day off work due to injury: MM/DD/YYYY First Period of Disability: Start Date MM/DD/YYYY End Date MM/DD/YYYY Second Period of Disability: 5. Compensation: Compensation was paid: Total paid: Weekly rate(s): Date of last payment: MM/DD/YYYY Start Date MM/DD/YYYY End Date MM/DD/YYYY Yes No 6. Has the worker received any unemployment insurance benefits and/or any unemployment compensation disability benefits (state disability) since the date of injury? Yes No DWC/WCAB Form 1A (11/2008) - (Page 3) WCAB1 7. Medical treatment: Medical treatment was received: All treatment was furnished by the Employer or Insurance Carrier: Date of last treatment: MM/DD/YYYY Yes Yes No No Other treatment was provided/paid by: (NAME OF PERSON OR AGENCY PROVIDING OR PAYING FOR MEDICAL CARE) Did Medi-Cal pay for any health care related to this claim? Yes No Names and addresses of doctor(s)/hospital(s)/clinic(s) that treated or examined for this injury, but that were not provided or paid for by the employer or insurance carrier: Name of Doctor/Hospital/Clinic 1 (Please leave blank spaces between numbers, names or words) Name of Doctor/Hospital/Clinic 2 (Please leave blank spaces between numbers, names or words) 8. Other cases have been filed for industrial injuries by this worker as follows: Case Number 1 Case Number 3 Case Number 2 Case Number 4 9. This application is filed because of a disagreement regarding liability for: Temporary disability indemnity Reimbursement for medical expense Medical treatment Compensation at proper rate Permanent disability indemnity Rehabilitation Supplemental Job Displacement/Return to Work Other (Specify) DWC/WCAB Form 1A (11/2008) - (Page 4) WCAB1 Is the Applicant Represented? Yes No If "No", applicant is to sign and date below. If "Yes", applicant's representative is to complete the following and is to sign and date below. Law Firm/Attorney Non-Attorney Representative Law Firm or Company Name (If Applicable) Law Firm Number (If Applicable) Attorney/Representative First Name MI Attorney/Representative Last Name Street Address/PO Box (Please leave blank spaces between numbers, names or words) City State Zip Code Applicant Attorney/Representative Signature Applicant Signature Dated at City Date MM/DD/YYYY , California DWC/WCAB Form 1A (11/2008) - (Page 5) WCAB1 INSTRUCTIONS FILING AND SERVICE OF A DECLARATION OF READINESS IS A PREREQUISITE TO THE SETTING OF A CASE FOR HEARING. Effect of Filing Application Filing of this application begins formal proceedings against the defendant(s) named in your application. Assistance in Filling Out Application You may request the assistance of an information and assistance officer of the Division of Workers' Compensation. Right to Attorney You may be represented by an attorney or agent, or you may represent yourself. The attorney's fee will be set by the Workers' Compensation Appeals Board at the time the case is decided and is ordinarily payable out of your award. Filling Out Application For "amended" applications, the venue choice must be the same as that specified on the original application, unless an order changing venue has issued. A street or P.O. Box address within the United States must be entered for the place where the injury occurred. Therefore, if the injury did not occur at a fixed or identifiable location (such as a f
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