STATE OF CALIFORNIA DIVISION OF WORKERS' COMPENSATION WORKERS' COMPENSATION APPEALS BOARD APPLICATION FOR ADJUDICATION OF CLAIM
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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 Lien Claimant
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) 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):
, while employed as a(n)
(DATE OF BIRTH: MM/DD/YYYY)
1. The injured worker, born
(OCCUPATION AT THE TIME OF INJURY)
(Choose only one) specific injury
suffered a :
(Date of injury: MM/DD/YYYY)
cumulative injury The injury occurred at
which began on
(Start Date: MM/DD/YYYY)
and ended on
(End Date: MM/DD/YYYY)
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: First Period of Disability: Second Period of Disability: 5. Compensation: Compensation was paid: Total paid: Weekly rate(s): Date of last payment:
MM/DD/YYYY MM/DD/YYYY
Start Date Start Date
MM/DD/YYYY
End Date End Date
MM/DD/YYYY
MM/DD/YYYY
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 Dated at Date
MM/DD/YYYY
Applicant Signature
City
, 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 field, a highway,or on water), or if the injury occurred outside of the United States, the employer's business address or another appropriate address must be specified; however, a short explanation regarding the place of injury may be appended to the application. If medical treatment has been paid for by Medi-Cal, Medicare, group health insurance, or a private carrier, please specify. Service of Documents Your attorney or agent will serve all documents in accordance with Labor Code section 5501 and the Workers' Compensation Appeals Board's Rules of Practice and Procedure. If you have no attorney or agent, copies of this application will be served by the Workers' Compensation Appeals Board on all parties. If you file any other document, you must mail or deliver a copy of the document to all parties in the case. IMPORTANT! If any applicant is under 18 years of age, it will be necessary to file a Petition for Appointment of Guardian ad Litem. Forms for this purpose may be obtained at the district office of the Workers' Compensation Appeals Board, or by calling the district office and requesting this form.
DWC/WCAB Form 1A (11/2008) - (Page 6)
WCAB1