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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)