Request For Dispute Resolution Before Administrative Director {DWC AD 10133.55}

DWC-AD form 10133.55 - REQUEST FOR DISPUTE RESOLUTION BEFORE ADMINISTRATIVE DIRECTOR. This form is used when the parties dispute issues related to the Supplemental Job Displacement Benefit (SJDB) in California workers’ compensation cases. The form collects detailed information about the employee, employer, claims administrator, legal representatives, and any vocational or return-to-work counselors involved. Requesters must specify the exact dispute—such as voucher entitlement, voucher amount, failure to pay a training provider, objections to a job offer, or another SJDB issue—and summarize prior informal resolution efforts. The form includes a proof of service section and instructions outlining timelines for responses, determinations, and potential appeals to the WCAB. www.FormsWorkflow.com