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.
Venue Choice: Completion of this section is required.
Dates: If Specific Injury, use the start date as the specific date of injury.
Penalties: Any accrued claims for Labor Code section 5814 penalties are included in this settlement unless expressly excluded.
Names and addresses: Please leave blank spaces between numbers, names or words.
| Question | Answer |
|---|---|
| Form Name | DWC-WCAB form 10214 (a) -1 |
| Form Length | 9 pages |
| Fillable? | Yes |
| Fillable fields | 203 |
| Avg. time to fill out | 34 min |
| Edition | Rev 5/2020 |
| Issuing agency | State of California Division of Workers' Compensation Workers' Compensation Appeals Board |
| Matches the agency's file | Yes, checked October 2, 2026 |
| Other names | DWC-WCAB form 10214 (a) -1, DWC-WCAB 10214 (a) -1, WCAB 10214(a)-1, DWC 10214(a)-1, 10214a1, Stipulations With Request for Award |
| Official source | DWC-WCAB form 10214 (a) -1 (Rev 5/2020), Division of Workers' Compensation |
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