Dwc Ad Form 10133 53 PDF Details

The DWC AD 10133.53 form plays a crucial role in the processes that govern workers' compensation claims in California, particularly for injuries occurring between January 1, 2004, and December 31, 2012. This document is essentially a notification of an offer of modified or alternative work from an employer to an employee who has sustained an injury during their tenure. The form meticulously outlines the responsibilities of both the claims administrator and the employee, with specific sections dedicated to the details of the offered position, including job title, salary, and essential duties, along with its physical requirements. Furthermore, it directs employees on how to respond to the offer, emphasizing the 30-day window they have to accept or reject it. Notably, the document does not shy away from discussing potential implications on the employee's permanent disability payments, highlighting a possible 15% decrease should they decide to refuse the offer without valid reasons listed within the form such as the job not meeting certain criteria related to salary, duration, and location relative to the employee's residence at the time of injury. This complex document underscores the intersection of employment law and workers' compensation regulations, requiring careful consideration from all parties involved to ensure a fair and legal handling of work-related injuries.

QuestionAnswer
Form NameDwc Ad Form 10133 53
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namesDWCADform10133_ 53 dwc ad form 1013353sjdb

Form Preview Example

State of California

Division of Workers' Compensation

NOTICE OF OFFER OF MODIFIED OR ALTERNATIVE WORK

FOR INJURIES OCCURRING BETWEEN 1/1/04 - 12/31/12, INCLUSIVE

DWC - AD 10133.53

THIS SECTION COMPLETED BY CLAIMS ADMINISTRATOR (All information in this section must be completed):

Claims Administrator Type: (Please Choose One)

Insurance Company

Third Party Administrator

Employer

Employer Name

is offering you

 

 

 

 

(Employee Name)

 

 

 

 

the position of a

 

 

 

 

.

 

 

 

 

 

 

Job Title

 

 

 

 

You may contact

 

 

 

 

 

 

 

 

concerning this offer. Phone No.:

 

Date of offer:

Date job starts:

 

 

 

 

 

 

MM/DD/YYYY

 

 

 

MM/DD/YYYY

Claims Administrator

Claim Number :

NOTICE TO EMPLOYEE (All information in this section must be completed)

Name of employee:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

First Name

 

 

 

Last Name

(Choose only one)

 

 

 

 

 

 

 

 

 

 

 

 

a specific injury on

 

 

 

 

 

 

 

 

 

 

 

 

 

MM/DD/YYYY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

a cumulative trauma injury which began on

 

 

 

and ended on

 

 

 

 

 

(START DATE: MM/DD/YYYY)

 

 

 

(END DATE: MM/DD/YYYY)

Date offer received:

 

 

 

 

 

 

 

Date of Birth:

 

 

 

 

MM/DD/YYYY

 

 

 

 

MM/DD/YYYY

You have 30 calendar days from receipt to accept or reject the attached offer of modified or alternative work. Regardless of whether you accept or reject this offer, the remainder of your permanent disability payments may be decreased by 15%. However, if you fail to respond in 30 days or reject this job offer, you will not be entitled to the supplemental job displacement benefit unless:

Modified Work

or Alternative Work

A. You cannot perform the essential functions of the job; or

B. The job is not a regular position lasting at least 12 months; or

C. Wages and compensation offered are less than 85% paid at the time of injury; or

D. The job is beyond a reasonable commuting distance from residence at time of injury.

DWC-AD form 10133.53 (SJDB) Rev: 1/1/14 Page 1 of 4

POSITION REQUIREMENTS (All information in this section must be completed)

Actual job title:

Wages: $

Per hour

 

Week

 

 

 

 

Month

 

Year

 

 

 

 

 

 

 

 

 

 

 

 

 

Is salary of modified/alternative work the same as pre-injury job?

 

Yes

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Is salary of modified/alternative work at least 85% of pre-injury job?

 

Yes

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Will job last at least 12 months?

 

 

Yes

 

No

 

 

 

 

Is the job a regular position required by the employer's business?

 

 

 

 

 

 

 

 

 

Yes

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Work location:

Duties required of the position:

Description of activities to be performed (if not stated in job description):

DWC-AD form 10133.53 (SJDB) Rev: 1/1/14 Page 2 of 4

Physical requirements for performing work activities (include modifications to usual and customary job):

Name of doctor who approved job restrictions (optional):

Date of report:

MM/DD/YYYY

Date of last payment of Temporary Total Disability:

MM/DD/YYYY

Preparer's Name:

Preparer's Signature:

Date:

MM/DD/YYYY

THIS SECTION TO BE COMPLETED BY EMPLOYEE (All information in this section must be completed)

I accept this offer of Modified or Alternative work.

I reject this offer of Modified or Alternative work and understand that I am not entitled to the Supplemental Job Displacement Benefit.

I understand that if I voluntarily quit prior to working in this position for 12 months, I may not be entitled to the Supplemental Job Displacement Benefit.

Signature:

 

Date:

 

 

 

MM/DD/YYYY

I feel I cannot accept this offer because:

DWC-AD form 10133.53 (SJDB) 11/13 Page 3 of 4

NOTICE TO THE PARTIES

If the offer is not accepted or rejected within 30 days of receipt of the offer, the offer is deemed to be rejected by the employee.

If a dispute occurs regarding the above offer or agreement, either party may request the Administrative Director to resolve the dispute by filing a Request for Dispute Resolution (Form DWC-AD 10133.55) with the Administrative Director, Division of Workers' Compensation, P.O. Box 420603, San Francisco, CA 94142-0603.

DWC-AD form 10133.53 (SJDB) Rev: 1/1/14 Page 4 of 4

How to Edit Dwc Ad Form 10133 53 Online for Free

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Be mindful when filling in this pdf. Make sure all necessary fields are filled out accurately.

1. The Dwc Ad Form 10133 53 needs certain information to be inserted. Make sure the following fields are complete:

Dwc Ad Form 10133 53 writing process outlined (step 1)

2. Once the first part is filled out, go on to enter the relevant details in these - NOTICE TO EMPLOYEE All information, Name of employee, Choose only one, First Name, Last Name, a specific injury on, MMDDYYYY, a cumulative trauma injury which, and ended on, START DATE MMDDYYYY, END DATE MMDDYYYY, Date offer received, MMDDYYYY, Date of Birth, and MMDDYYYY.

Tips to fill out Dwc Ad Form 10133 53 portion 2

3. Completing POSITION REQUIREMENTS All, Actual job title, Wages, Per hour, Week, Month, Year, Is salary of modifiedalternative, Is salary of modifiedalternative, Will job last at least months, Is the job a regular position, Yes, Yes, Yes, and Yes is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

Completing segment 3 in Dwc Ad Form 10133 53

4. Filling in Description of activities to be is key in this form section - be certain to take your time and take a close look at each and every blank!

The best ways to complete Dwc Ad Form 10133 53 step 4

Always be really attentive when filling in Description of activities to be and Description of activities to be, as this is where many people make a few mistakes.

5. This final notch to conclude this form is essential. Make certain you fill in the mandatory blank fields, for instance Physical requirements for, Name of doctor who approved job, Date of report, MMDDYYYY, Date of last payment of Temporary, and MMDDYYYY, prior to submitting. Failing to do it might end up in an unfinished and potentially incorrect document!

A way to fill out Dwc Ad Form 10133 53 step 5

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