Dwc Ca Form 10214 – Fill Out and Use This PDF

STATE OF CALIFORNIA

DIVISION OF WORKERS' COMPENSATION

WORKERS' COMPENSATION APPEALS BOARD

STIPULATIONS WITH REQUEST FOR AWARD

Date of Injury

MM/DD/YYYY

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)

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	State	Zip Code

Employer #1 Information (Completion of this section is required)

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)
				State
						Zip Code
City

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

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

State

Zip Code

Employer #3 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

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

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

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

,

State

as a(n)

,

in

Occupation

Group

DWC-CA form 10214 (a) Page 4 (Rev 11/2008)

2. The injury (ies) caused temporary disability for the period

through

MM/DD/YYYY

for which indemnity has been paid at $

per week.

MM/DD/YYYY

Indemnity Paid

2(a).The injury(ies) caused additional temporary disability for the period

MM/DD/YYYY

through

at the rate of $

in the amount of $

MM/DD/YYYY

Rate

Indemnity Paid

3. The injury(ies) caused permanent disability of

% for which indemnity is payable at $

Indemnity Rate

per week beginning

in the sum of $

, less credit for such payments

MM/DD/YYYY

4.There

is

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:

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
					Applicant Attorney Signature
		MM/DD/YYYY

DWC-CA form 10214 (a) Page 7 (Rev 11/2008)

Defendant's Attorney or Authorized 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

Defendant's Attorney or Authorized 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

DWC-CA form 10214 (a) Page 8 (Rev 11/2008)

Defendant's Attorney or Authorized 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

Interpreter Name		Interpreter License Number

DWC-CA form 10214 (a) Page 9 (Rev 11/2008)