Dwc Wcab Form 10214 A 1 PDF Details

Understanding the intricacies of the DWC WCAB 10214 A 1 form is essential for individuals and attorneys navigating through workers' compensation cases in California. This form, integral to the State of California's Division of Workers' Compensation and the Workers' Compensation Appeals Board, facilitates a streamlined process for stipulating the key aspects of a case and requesting awards based on agreed facts. The form allows for the specification of the date of injury, case number, and pertinent details of the claimant, employer, insurance carrier, and claims administrator. It also enables the selection of venue based on the county of the employee's residence, the place of injury, or the principal place of business of the employee's attorney, ensuring the case is heard in a relevant jurisdiction. Detailed sections for entering employer and insurance information ensure all parties involved are accurately documented, which is crucial for case management and proceedings. Moreover, the form addresses situations with multiple employers, accommodating claims that might arise from complex work scenarios. As it articulates the agreement between parties on the facts of the case and bypasses the usual requirements for hearings per Labor Code section 5313, its completion is a critical step in expediting the resolution of workers’ compensation claims. In addition to basic information, the form allows for the documentation of injuries sustained, categorizing them as specific or cumulative and detailing the body parts involved, thereby providing a comprehensive scope of the injury for review and award determination. This introductory overview reflects the form's utility in simplifying and facilitating the resolution of workers' compensation cases by providing a structured format for the presentation of vital information.

QuestionAnswer
Form NameDwc Wcab Form 10214 A 1
Form Length9 pages
Fillable?No
Fillable fields0
Avg. time to fill out2 min 15 sec
Other namesliens, issuance, CALIFORNIA, dwc

Form Preview Example

 

 

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)

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

DWC-WCAB form 10214 (a) -1 Page 1 (Rev 4/2014)

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-WCAB form 10214 (a) -1 Page 2 (Rev 4/2014)

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-WCAB form 10214 (a) -1 Page 3 (Rev 4/2014)

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-WCAB form 10214 (a) -1 Page 4 (Rev 4/2014)

More than 4 Companion Cases

Specific Injury

Case Number 1

Cumulative Injury

(Start Date: MM/DD/YYYY)

 

(End Date: MM/DD/YYYY)

 

 

(If Specific Injury, use the start date as the specific date of injury)

 

 

 

 

 

 

 

 

Body Part 1:

 

 

Body Part 2:

 

 

Body Part 3:

 

Body Part 4:

 

 

Other Body Parts:

 

 

 

 

 

 

 

 

Specific Injury

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Case Number 2

Cumulative Injury

(Start Date: MM/DD/YYYY)

 

(End Date: MM/DD/YYYY)

 

 

 

 

 

 

 

 

(If Specific Injury, use the start date as the specific date of injury)

Body Part 1:

 

 

Body Part 2:

 

 

Body Part 3:

 

Body Part 4:

 

 

Other Body Parts:

 

 

 

 

 

 

 

 

Specific Injury

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Case Number 3

 

 

 

 

 

 

 

 

 

 

 

Cumulative Injury

(Start Date: MM/DD/YYYY)

 

(End Date: MM/DD/YYYY)

 

 

 

 

 

 

 

 

(If Specific Injury, use the start date as the specific date of injury)

Body Part 1:

 

 

Body Part 2:

 

 

Body Part 3:

 

Body Part 4:

 

 

Other Body Parts:

 

 

 

 

 

 

 

 

Specific Injury

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Case Number 4

Cumulative Injury

(Start Date: MM/DD/YYYY)

 

(End Date: MM/DD/YYYY)

 

 

 

 

 

 

 

 

(If Specific Injury, use the start date as the specific date of injury)

Body Part 1:

 

 

Body Part 2:

 

 

Body Part 3:

 

Body Part 4:

 

 

Other Body Parts:

 

 

 

 

 

 

by the employer(s) and their insurer(s) listed above and who sustained injury(ies) arising out of and in the course of employment to

(Please list all body parts injured)

DWC-WCAB form 10214 (a) -1 Page 5 (Rev 4/2014)

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

previously made.

And a life pension of $

per week thereafter.

Life Pension

An informal rating

has /

has not (Select one) been previously issued in case no(s)

 

.

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-WCAB form 10214 (a) -1 Page 6 (Rev 4/2014)

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:

Law Firm/Attorney

Non Attorney 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-WCAB form 10214 (a) -1 Page 7 (Rev 4/2014)

Defendant's Attorney or Authorized Representative:

Law Firm/Attorney

Non Attorney 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:

Law Firm/Attorney

Non Attorney 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-WCAB form 10214 (a) -1Page 8 (Rev 4/2014)

Defendant's Attorney or Authorized Representative:

Law Firm/Attorney

Non Attorney 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

Interpreter License Number:

Defense Attorney Signature

Interpreter Name

 

Interpreter License Number

 

 

DWC-WCAB form 10214 (a) -1 Page 9 (Rev 4/2014)

How to Edit Dwc Wcab Form 10214 A 1 Online for Free

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1. While submitting the liens, make certain to incorporate all important blanks within its corresponding section. This will help to facilitate the process, enabling your information to be handled efficiently and appropriately.

Filling in segment 1 of dwc ca form 10214

2. When the prior part is done, proceed to type in the applicable information in these: First Name, Last Name, AddressPO Box Please leave blank, City, State, Zip Code, Employer Information Completion, Insured, SelfInsured, Legally Uninsured, Uninsured, Employer Name Please leave blank, and Employer Street AddressPO Box.

Legally Uninsured, Insured, and Employer Information Completion of dwc ca form 10214

Regarding Legally Uninsured and Insured, make certain you take another look in this section. Those two are surely the most significant fields in the file.

3. This next segment should also be rather simple, Insurance Carrier Information if, Insurance Carrier Name Please, Insurance Carrier Street AddressPO, City, State, Zip Code, Claims Administrator Information, Name Please leave blank spaces, Street AddressPO Box Please leave, City, State, Zip Code, and Employer Information Completion - these blanks has to be filled in here.

Completing segment 3 of dwc ca form 10214

4. This next section requires some additional information. Ensure you complete all the necessary fields - Insured, SelfInsured, Legally Uninsured, Uninsured, Employer Name Please leave blank, Employer Street AddressPO Box, City, State, Zip Code, Insurance Carrier Information if, and Insurance Carrier Name Please - to proceed further in your process!

Filling out segment 4 of dwc ca form 10214

5. The document should be completed with this section. Below you will notice a detailed listing of blank fields that have to be completed with appropriate information to allow your form submission to be faultless: Insurance Carrier Street AddressPO, City, State, Zip Code, and DWCWCAB form a Page Rev.

State, Zip Code, and Insurance Carrier Street AddressPO of dwc ca form 10214

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