Dwc Ca Form 10214 D PDF Details

When individuals navigate the complexities of workers' compensation claims, especially in the tragic event of a work-related death, the DWC-CA form 10214 (d) serves as a critical document within the State of California. This specific form, entitled "Compromise and Release (Dependency Claim)," is designed to facilitate the resolution of claims by dependents of an employee who has suffered a fatal injury in the course of their employment. Essential elements covered in the form include the basic identification details of the employee and employer, insurance carrier information, and the specification of the injury and consequent death details. Furthermore, it captures the dependency details of the claimants, outlines the agreement on settlement amounts, and delineates any agreed-upon medical, hospital, and burial expenses. The form also addresses if the applicant is represented by an attorney, the reason for the compromise, and a comprehensive release clause absolving the employer and insurance carrier from further claims in relation to the employee's death. With provisions for documenting payment divisions for various claims and a process for legal review and approval, this form encapsulates the agreement between the parties involved, aiming to conclude the compensation process efficiently and equitably.

QuestionAnswer
Form NameDwc Ca Form 10214 D
Form Length6 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 30 sec
Other namesCompromise and release (dependency claim) compromise and release workers comp california writable form

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STATE OF CALIFORNIA

DIVISION OF WORKERS' COMPENSATION

WORKERS' COMPENSATION APPEALS BOARD

COMPROMISE AND RELEASE

(Dependency claim)

Case Number 1

Case Number 2

Case Number 3

Case Number 4

Case Number 5

SSN (Numbers Only)

Venue Choice is based upon: (Completion of this section is required)

Residence of employee (Labor Code section 5501.5(a)(1))

Location where injury occurred (Labor Code section 5501.5(a)(2))

Principal address of employee’s attorney (Labor Code section 5501.5(a)(3))

Select 3 Letter Office Code For Place/Venue of Hearing (From Document Cover Sheet)

Employee (Completion of this section is required)

First Name

MI

Last Name

Address/PO Box (Please leave blank spaces between numbers, names or words)

City

 

State

 

Zip Code

Employer (Completion of this section is required)

Name (Please leave blank spaces between numbers, names or words)

Address/PO Box (Please leave blank spaces between numbers, names or words)

City

State

Zip Code

DWC-CA form 10214 (d) (PAGE 1) (REV. 07/2008)

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1. The below - named dependent(s)

claims that

 

 

 

 

 

 

 

 

 

 

 

 

 

 

( NAME OF EMPLOYEE )

while employed at

 

 

 

 

 

on

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of Injury: MM/DD/YYYY

by

 

 

 

 

, then insured as to worker's compensation liability

 

 

(NAME OF EMPLOYER )

 

 

 

 

 

 

 

by

 

 

sustained injury arising out of and in the course of such

 

(STATE NAME OF CARRIER OR WHETHER SELF - INSURED)

 

 

 

 

 

 

 

 

 

 

 

employment as follows:

2.

The death of the said employee occurred on

 

 

 

 

 

Date of Employee Death: MM/DD/YYYY

3.

The actual weekly wages of the employee at the time of claimed injury were,

average weekly wages (statutory) were

 

 

.

, as a result of the claimed injury.

, while

4. Payments of compensation to the employee in his lifetime on the account of the claimed injury were

 

.

DWC-CA form 10214 (d) (PAGE 2) (REV. 07/2008)

5.The applicant(s) herein claims to have been dependent upon said employee at the time of the claimed injury and states the name(s), age(s), relationship to, and the extent of dependency upon the deceased employee to have been as follows:

Dependent # 1 of Employee

First Name

MI

Last Name

Extent of dependency

Age Relationship

Partial

Total

Dependent # 2 of Employee

First Name

MI

Last Name

Extent of dependency

Age Relationship

Partial

Total

Dependent # 3 of Employee

Fisrt Name

MI

Last Name

Extent of dependency

Age Relationship

Partial

Total

6. The parties hereby agree to settle any and all claims of said dependent(s) on account of the claimed injury and the death of said

employee by the payment of sum of $

 

, payable as follows to:

 

 

 

 

 

 

 

7.The parties hereby agree (if such items of expense be claimed) that medical, hospital and burial expense required by reason of alleged injury and death of employee shall be borne as follows:

DWC-CA form 10214 (d) (PAGE 3) (REV. 07/2008)

8. 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/Rep First Name

MI

Attorney/Rep Last Name

Street Address/PO Box (Please leave blank spaces between numbers, names or words)

City

 

 

 

State

 

Zip Code

 

 

who requested a fee of $

 

, having been previously paid $

 

 

 

 

9. Reason for compromise

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10.The undersigned request that this compromise agreement and release be approved.

11.Upon the approval of this compromise agreement as provided by law, and payment in accordance with the provision of the said order of approval, said applicants and each of them do hereby release and forever discharge said employer and said insurance company of and from all claims, demands, actions or causes of action, of every kind or nature whatsoever on account of, or by reason of injury and death sustained as aforesaid by the employee, and in particular of any, all and every claim or cause of action which the undersigned, heirs, executors, representatives, and administrators may have had, now have, or shall hereafter have against said employer, said insurance carrier, and each of them under Division 4 of the Labor Code of the State of California.

DWC-CA form 10214 (d) (PAGE 4) (REV. 07/2008)

12.It is agreed by all parties hereto that the filing of this document is filing of an application on behalf of the applicant and that it may be set for hearing as a regular application, reserving to the parties the right to put in issue any of the facts admitted herein, and that if hearing is held with this document used as an application the defendants shall have available to them all defenses that were available as of date of filing this document, and that it may thereafter be approved, disapproved, or a decision issued after a hearing has been held and the matter regularly submitted.

13.For the purpose of determining the lien claim filed herein for the unemployment compensation disability and / or unemployment compensation benefits which have been paid under or pursuant to California Unemployment Insurance Code, the parties propose the following division of sum agreed upon for settlement and release of this case:

$

 

 

 

for temporary disability covering the period

 

to

 

.

$

 

 

for accrued medical expense paid or incurred by the employee.

 

 

 

 

 

 

for future medical care.

 

 

 

$

 

 

 

 

 

 

$

 

 

 

for permanent disability.

 

 

 

(The above segregation must be fair and reasonable and must be based on the real facts of the case. There should be no attempt made to deprive the lien claimant of a reasonable recovery consistent with all amounts involved.)

Witness the execution hereof this______________ day of ______________________, ______________________, at

 

Witness 1

(Date)

 

 

 

 

 

 

Witness 2

(Date)

 

 

 

 

 

 

Interpreter

(Date)

 

Applicant (Employee)

Attorney for Applicant

Attorney for Defendant

Attorney for Defendant

Attorney for Defendant

(Date)

(Date)

(Date)

(Date)

(Date)

Attorney for Defendant

(Date)

DWC-CA form 10214 (d) (PAGE 5) (REV. 07/2008)

ACKNOWLEDGMENT

State of California

County of _____________________________)

On _________________________ before me, _________________________________________

(insert name and title of the officer)

personally appeared ______________________________________________________________,

who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.

I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct.

WITNESS my hand and official seal.

Signature ______________________________

(Seal)

 

 

DWC-CA form 10214 (d) (PAGE 6) (REV. 07/2008)

How to Edit Dwc Ca Form 10214 D Online for Free

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It will be easy to complete the pdf with this practical tutorial! This is what you want to do:

1. When submitting the Dwc Ca Form 10214 D, make certain to complete all essential blank fields within its relevant part. This will help facilitate the process, which allows your details to be processed fast and appropriately.

Step no. 1 of filling out Dwc Ca Form 10214 D

2. After this part is completed, proceed to enter the suitable details in these - First Name, Last Name, AddressPO Box Please leave blank, City, State, Zip Code, Employer Completion of this, Name Please leave blank spaces, AddressPO Box Please leave blank, City, State, and Zip Code.

Dwc Ca Form 10214 D conclusion process clarified (stage 2)

Always be extremely attentive when filling in Zip Code and City, since this is where most users make some mistakes.

3. Through this stage, check out Insurance Carrier Information if, Insurance Carrier Name Please, Insurance Carrier Street AddressPO, City, State, Zip Code, Claims Administrator Information, Name Please leave blank spaces, and Street AddressPO Box Please leave. All of these have to be filled in with highest accuracy.

Insurance Carrier Name Please, Street AddressPO Box Please leave, and Claims Administrator Information inside Dwc Ca Form 10214 D

4. The next paragraph will require your input in the following places: The below named dependents, while employed at, NAME OF EMPLOYER, STATE NAME OF CARRIER OR WHETHER, employment as follows, NAME OF EMPLOYEE, Date of Injury MMDDYYYY, then insured as to workers, sustained injury arising out of, The death of the said employee, as a result of the claimed injury, and Date of Employee Death MMDDYYYY. Be sure to fill in all required information to go forward.

Filling out segment 4 of Dwc Ca Form 10214 D

5. The last point to finalize this document is essential. Ensure to fill out the required form fields, which includes The actual weekly wages of the, while, average weekly wages statutory were, Payments of compensation to the, and DWCCA form d PAGE REV, prior to using the form. If you don't, it might produce an incomplete and potentially nonvalid paper!

Filling in segment 5 in Dwc Ca Form 10214 D

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