Free Pre-Trial Conference Statement - California

STATE OF CALIFORNIA
DEPARTMENT OF INDUSTRIAL RELATIONS


WORKERS' COMPENSATION APPEALS BOARD

CASE NO. APPLICANT V.

DEFENDANT(S).

PRE-TRIAL CONFERENCE STATEMENT §5502 NOTICE OF HEARING TIME:

(d) (3)

LOCATION: SETTLEMENT CONFERENCE JUDGE: APPEARANCES:

DATE:



INJURED WORKER: INJURED WORKER'S ATTORNEY

ATTY HRG REP

(FIRM NAME AND PERSON APPEARING)

DEFENDANT'S ATTORNEY

ATTY HRG REP ATTY HRG REP ATTY HRG REP ATTY HRG REP

(FIRM NAME AND PERSON APPEARING)

OTHERS APPEARING: (L.C., INTERPRETERS, ETC.) ADDRESS RECORD CHANGES:

(DEFENDANT)

BOX BELOW TO BE COMPLETED ONLY BY WORKERS' COMPENSATION JUDGE

DISPOSITION: SET FOR REGULAR HEARING:
1 HOUR 2 HOURS ½ DAY BEFORE ANY WCJ BEFORE WCJ CASE(S) SET ON AT (DATE) (TIME)
ALL DAY

WCAB NOTICE

NOTICE WAIVED

BEFORE ANY WCJ OTHER THAN
WCJ IN

(LOCATION)

OTHER DISPOSITION AND ORDERS:

SERVICE AS ORDERED ON PAGE 4 WORKERS' COMPENSATION ADMINISTRATIVE LAW JUDGE

DWC CA form 10253.1 (Rev 11/2008)

PRE-TRIAL CONFERENCE STATEMENT

CASE NO.

STIPULATIONS
THE FOLLOWING FACTS ARE ADMITTED:

1.
WHILE

, BORN ____/____/____
EMPLOYED ALLEGEDLY EMPLOYED

ON DURING THE PERIOD(S)

AS A(N) AT BY

,

OCCUPATIONAL GROUP NUMBER

,

CALIFORNIA,

SUSTAINED INJURY ARISING OUT OF AND IN THE COURSE OF EMPLOYMENT TO

CLAIMS TO HAVE SUSTAINED INJURY ARISING OUT OF AND IN THE COURSE OF EMPLOYMENT TO

2.

AT THE TIME OF INJURY THE EMPLOYER'S WORKERS' COMPENSATION CARRIER WAS

THE EMPLOYER WAS

PERMISSIBLY SELF-INSURED

UNINSURED

LEGALLY UNINSURED
PER WEEK, WARRANTING INDEMNITY FOR PERMANENT DISABILITY.

3.

AT THE TIME OF INJURY, THE EMPLOYEE'S EARNINGS WERE $ RATES OF $ FOR TEMPORARY DISABILITY AND $

4.

THE CARRIER/EMPLOYER HAS PAID COMPENSATION AS FOLLOWS: WEEKLY RATE PERIOD

(TD/PD/VRMA)

TYPE WEEKLY RATE PERIOD


TYPE

THE EMPLOYEE HAS BEEN ADEQUATELY COMPENSATED FOR ALL PERIODS OF T/D CLAIMED THROUGH

5.

THE EMPLOYER HAS FURNISHED

ALL

SOME

NO MEDICAL TREATMENT.

THE PRIMARY TREATING PHYSICIAN IS

6. 7.

NO ATTORNEY FEES HAVE BEEN PAID AND NO ATTORNEY FEE ARRANGEMENTS HAVE BEEN MADE. OTHER STIPULATIONS

APPLICANT

DEFENDANT

LIEN CLAIMANT/OTHER

PAGE 2

DWC CA form 10253.1 (Rev 11/2008)

PRE-TRIAL CONFERENCE STATEMENT ISSUES
EMPLOYMENT INSURANCE COVERAGE INJURY ARISING OUT OF AND IN THE COURSE OF EMPLOYMENT PARTS OF BODY INJURED: EARNINGS: EMPLOYEE CLAIMS
EMPLOYER/CARRIER CLAIMS

CASE NO.

PER WEEK, BASED ON PER WEEK, BASED ON

TEMPORARY DISABILITY, EMPLOYEE CLAIMING THE FOLLOWING PERIOD(S):

PERMANENT AND STATIONARY DATE:
EMPLOYEE CLAIMS ____/____/____, BASED ON EMPLOYER/CARRIER CLAIMS ____/____/____, BASED ON

PERMANENT DISABILITY

APPORTIONMENT

OCCUPATION AND GROUP NUMBER CLAIMED: BY EMPLOYEE BY EMPLOYER/CARRIER

NEED FOR FURTHER MEDICAL TREATMENT LIABILITY FOR SELF-PROCURED MEDICAL TREATMENT

LIENS:

LIEN CLAIMANT TYPE OF LIEN AMOUNT AND PERIODS PAID


ATTORNEY FEES OTHER ISSUES:

APPLICANT

DEFENDANT

LIEN CLAIMANT/OTHER

PAGE 3

DWC CA form 10253.1 (Rev 11/2008)

PRE-TRIAL CONFERENCE STATEMENT
THIS PAGE FOR JUDGE'S USE ONLY


CASE NO.

___________________


JUDGE'S CONFERENCE NOTES:




ORDERS

IT IS ORDERED PURSUANT TO WCAB RULE 10500, THAT DEFENDANT
FORTHWITH THIS



APPLICANT

LIEN CLAIMANT SERVE



PRE-TRIAL CONFERENCE STATEMENT

NOTICE OF HEARING ON ALL PARTIES OR THEIR REPRESENTATIVE

SHOWN ON THE OFFICIAL ADDRESS RECORD AND ANY ADDITIONAL LIEN CLAIMANTS WHOSE LIENS ARE SHOWN UNDER ISSUES (PAGE

3).
IT IS FURTHER ORDERED THAT DEFENDANT APPLICANT LIEN CLAIMANT SERVE TIMELY NOTICE OF THE TIME AND
PLACE OF ALL REGULAR HEARING SESSIONS ON ALL LIEN CLAIMANTS WHOSE LIENS ARE SHOWN UNDER ISSUES, TOGETHER WITH THE FOLLOWING NOTICE: YOUR LIEN IS AT ISSUE AND WILL BE ADJUDICATED AT REGULAR HEARING.

IT IS FURTHER ORDERED THAT THE PROOF OF SERVICE ORDERED ABOVE BE FILED WITH THE WCAB ONLY ON REQUEST OF THE ASSIGNED WORKERS' COMPENSATION JUDGE.

OTHER DISPOSITION AND ORDERS

SERVICE OF THIS DOCUMENT WAS MADE PERSONALLY UPON


BY WCJ.


DATE _____/_____/_____ WORKERS' COMPENSATION ADMINISTRATIVE LAW JUDGE

PAGE 4

DWC CA form 10253.1 (Rev 11/2008)

PRE-TRIAL CONFERENCE STATEMENT

CASE NO.

EXHIBITS

APPLICANT DEFENDANT LIEN CLAIMANT APPEALS BOARD

DESCRIPTION

DATE

W ITNESSES

ABOVE LISTINGS OF EXHIBITS AND WITNESSES REVIEWED BY ALL PARTIES.

APPLICANT PAGE ___ OF ___

DEFENDANT

LIEN CLAIMANT/OTHER

DWC CA form 10253.1 (Rev 11/2008)

PRE-TRIAL CONFERENCE STATEMENT (MULTIPLE PARTIES)

CASE NO(S)

1.

APPLICANT, BORN

, (1)

SUSTAINED OR CLAIMS INJURY AS FOLLOWS:

(2)

(3)

(4)

CASE NO. DOI CLAIMS ADMITTED BODY PARTS JOB TITLE(S) OCCUPATIONAL GROUP NO(S). EARNINGS & TD/PD RATES EMPLOYER CARRIER ADJUSTED BY WORK COMP SECURED BY COVERAGE DATES INSURED SELF-INSURED UNINSURED



CLAIMS ADMITTED



CLAIMS ADMITTED



CLAIMS ADMITTED





INSURED SELF-INSURED UNINSURED



INSURED SELF-INSURED UNINSURED



INSURED SELF-INSURED UNINSURED



2.

THE CARRIER/EMPLOYER HAS PAID COMPENSATION AS FOLLOWS: TYPE WEEKLY RATE PERIOD PAID BY

3.

THE EMPLOYEE HAS BEEN ADEQUATELY COMPENSATED FOR ALL PERIODS OF TEMPORARY DISABILITY CLAIMED . THROUGH SOME NO MEDICAL TREATMENT.

4.

THE EMPLOYER HAS FURNISHED ALL THE PRIMARY TREATING PHYSICIAN IS

.

5. 6.

NO ATTORNEY FEES HAVE BEEN PAID AND NO ATTORNEY FEE AGREEMENTS HAVE BEEN MADE. OTHER STIPULATIONS:

PAGE _____

DWC CA form 10253.1 (Rev 11/2008)