State of California Division of Workers' Compensation Retraining and Return to Work Unit REQUEST FOR DISPUTE RESOLUTION BEFORE ADMINISTRATIVE DIRECTOR DWC - AD 10133.55
Original Employer Accepted Claim Liability found by WCAB More than 60 Days Since TTD Ended Has PPD been stipulated, issued/ approved Claim Number Response
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SSN (Numbers Only) Employee (All information in this section must be completed)
Case Number
First Name
MI
Last Name
Street Address /PO Box (Please leave blank spaces between numbers, names or words)
City DOB
State
Zip Code
Phone (Choose only one)
a specific injury on
MM/DD/YYYY
MM/DD/YYYY
a cumulative trauma injury which began on
(START DATE: MM/DD/YYYY)
and ended on
(END DATE: MM/DD/YYYY)
DWC-AD form 10133.55 (SJDB) Rev: 11/2008 - ( Page 1)
10133.55
Employee Representative (If Applicable)
Name
Address/PO Box (Please leave blank spaces between numbers, names or words)
City
Phone
State
Zip Code
Employer (All information in this section must be completed) Insured Self-Insured Legally Uninsured Uninsured
Name
Employer Street Address/PO Box (Please leave blank spaces between numbers, names or words)
City
State
Zip Code
Phone Employer Representative (if known and If applicable) Name
Address/PO Box (Please leave blank spaces between numbers, names or words)
City Phone 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
DWC-AD form 10133.55(SJDB) Rev: 11/2008 - ( Page 2)
State
Zip Code
10133.55
Vocational & Return to Work Counselor (if applicable)
Name
Firm Name
Address/PO Box (Please leave blank spaces between numbers, names or words)
City Phone
State
Zip Code
Administrative Director Requested to resolve the following dispute because the parties disagree on (All information in this section must be completed): Employee's entitlement to a voucher. The parties dispute the amount of the voucher. The insurer has failed to pay training provider per title 8, California Code of Regulations sections 10133.57 and 10133. 58, and/or the VRTWC per title 8 California Code of Regulations sections 10133.57 and 10133.59. The employee objects to the new job duties provided by the employer. The employer objects to the amount of reimbursement approved or denied. Other
Summary of informal efforts to resolve dispute
Requester Name
Date Signature
DWC-AD form 10133.55(SJDB) Rev: 11/2008 - ( Page 3)
MM/DD/YYYY
10133.55