Free DWC-CA form 10214 (a) - California


File Size: 629.1 kB
Pages: 9
Date: November 17, 2008
File Format: PDF
State: California
Category: Workers Compensation
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Word Count: 1,342 Words, 8,669 Characters
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URL

http://www.dir.ca.gov/dwc/FORMS/EAMS%20Forms/ADJ/DWCForm10214a.pdf

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STATE OF CALIFORNIA DIVISION OF WORKERS' COMPENSATION WORKERS' COMPENSATION APPEALS BOARD STIPULATIONS WITH REQUEST FOR AWARD
Date of Injury 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).)
MM/DD/YYYY

Select 3 Letter Office Code For Place/Venue of Hearing (From the Document Cover Sheet) Applicant (Completion of this section is required)

First Name

MI

Last Name

Address/PO Box (Please leave blank spaces between numbers, names or words)

City Employer #1 Information (Completion of this section is required) Insured Self-Insured Legally Uninsured

State

Zip Code

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

DWC-CA form 10214 (a) Page 1 (Rev 11/2008)

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

Employer #2 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 Insurance Carrier Information (if known and if applicable - include even if carrier is adjusted by claims administrator)

State

Zip Code

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

DWC-CA form 10214 (a) Page 2 (Rev 11/2008)

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 Employer #3 Information (Completion of this section is required) Insured Self-Insured Legally Uninsured

State

Zip Code

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 Insurance Carrier Information (if known and if applicable - include even if carrier is adjusted by claims administrator)

State

Zip Code

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 Claims Administrator Information (if known and if applicable)

State

Zip Code

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

DWC-CA form 10214 (a) Page 3 (Rev 11/2008)

Employer #4 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 Insurance Carrier Information (if known and if applicable - include even if carrier is adjusted by claims administrator)

Zip Code

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

The parties hereto stipulate to the issuance of an Award and/or Order, based upon the following facts, and waive the requirements of Labor Code section 5313: 1.

Employees First Name , Employees Last Name
birth date

MM/DD/YYYY

, , ,

while employed at as a(n)
DWC-CA form 10214 (a) Page 4 (Rev 11/2008)

State in

Occupation

Group

More than 4 Companion Cases Specific Injury Case Number 1 Cumulative Injury
(Start Date: MM/DD/YYYY) (End Date: MM/DD/YYYY) (If Specific Injury, use the start date as the specific date of injury)

Body Part 1: Body Part 4:

Body Part 2: Other Body Parts: Specific Injury

Body Part 3:

Case Number 2

Cumulative Injury

(Start Date: MM/DD/YYYY) (End Date: MM/DD/YYYY) (If Specific Injury, use the start date as the specific date of injury)

Body Part 1: Body Part 4:

Body Part 2: Other Body Parts: Specific Injury

Body Part 3:

Case Number 3

Cumulative Injury

(Start Date: MM/DD/YYYY) (End Date: MM/DD/YYYY) (If Specific Injury, use the start date as the specific date of injury)

Body Part 1: Body Part 4:

Body Part 2: Other Body Parts: Specific Injury

Body Part 3:

Case Number 4

Cumulative Injury

(Start Date: MM/DD/YYYY) (End Date: MM/DD/YYYY) (If Specific Injury, use the start date as the specific date of injury)

Body Part 1: Body Part 4:

Body Part 2: Other Body Parts:

Body Part 3:

by the employer(s) and their insurer(s) listed above and who sustained injury(ies) arising out of and in the course of employment to

(Please list all body parts injured)
DWC-CA form 10214 (a) Page 5 (Rev 11/2008)

2. The injury (ies) caused temporary disability for the period

MM/DD/YYYY

through per week.

for which indemnity has been paid at $
MM/DD/YYYY Indemnity Paid

2(a).The injury(ies) caused additional temporary disability for the period
MM/DD/YYYY

through

MM/DD/YYYY

at the rate of $

Rate

in the amount of $

Indemnity Paid

3. The injury(ies) caused permanent disability of per week beginning previously made.
MM/DD/YYYY

% for which indemnity is payable at $ in the sum of $
Life Pension

Indemnity Rate

, less credit for such payments

And a life pension of $

per week thereafter.

Labor Code ยง4658(d) adjustment:
Increase rate to $

as of

MM/DD/YYYY

Decrease rate to $ Not Applicable

as of

MM/DD/YYYY

An informal rating 4.There is

has /

has not (Select one) been previously issued in case no(s)

.

is Not a need for medical treatment to cure or relieve from the effects of said injury (ies).

5. Medical-legal expenses and/or liens are payable by defendant as follows:

6. Applicant's attorney requests a fee of $ Fees to be commuted as follows:

7. Liens Against compensation are payable as follows:

DWC-CA form 10214 (a) Page 6 (Rev 11/2008)

8.Any accrued claims for Labor Code section 5814 penalties are included in this settlement unless expressly excluded. 9.Other stipulations:

Dated

MM/DD/YYYY

Applicant

Applicant's Attorney or Authorized Representative: Law Firm/Attorney Non Attorney Representative

First Name

Last Name

Firm Number

Law Firm name

Address/PO Box (Please leave blank spaces between numbers, names or words)

City

State

Zip Code

Dated

MM/DD/YYYY

Applicant Attorney Signature

DWC-CA form 10214 (a) Page 7 (Rev 11/2008)

Defendant's Attorney or Authorized Representative: Law Firm/Attorney Non Attorney Representative

First Name

Last Name

Firm Number

Law Firm Name

Address/PO Box (Please leave blank spaces between numbers, names or words)

City

State

Zip Code

Dated

MM/DD/YYYY

Defense Attorney Signature Non Attorney Representative

Defendant's Attorney or Authorized Representative: Law Firm/Attorney

First Name

Last Name

Firm Number

Law Firm Name

Address/PO Box (Please leave blank spaces between numbers, names or words)

City

State
MM/DD/YYYY

Zip Code

Dated

Defense Attorney Signature
DWC-CA form 10214 (a) Page 8 (Rev 11/2008)

Defendant's Attorney or Authorized Representative: Law Firm/Attorney Non Attorney Representative

First Name

Last Name

Firm Number

Law Firm Name

Address/PO Box (Please leave blank spaces between numbers, names or words)

City

State

Zip Code

Dated

MM/DD/YYYY

Defense Attorney Signature

Interpreter Licence Number:

Interpreter Name

Interpreter License Number

DWC-CA form 10214 (a) Page 9 (Rev 11/2008)