Form Dwc Ad 10133 55 PDF Details

The DWC-AD 10133.55 form serves as a crucial document within the realm of workers' compensation in California, specifically designed to facilitate the dispute resolution process when disagreements arise regarding the acceptance of a claim, liability for an injury, the conclusion of temporary total disability (TTD) payments, or the issuance/approval of permanent partial disability (PPD) awards. This form, utilized exclusively by the Workers' Compensation Appeals Board (WCAB) and the Administrative Director, encompasses fields that capture essential information such as the employer's and employee's details, insurance or self-insurance certificate name, adjusting agency, and representatives of both parties, among others. It sets a procedural framework for both parties to concisely document their standpoints, summarize their informal efforts to reach a resolution, and officially request the intervention of the Administrative Director. Moreover, it stipulates the mandatory provision of proof of service to ensure that all involved parties are properly notified. The specific inclusion of checkboxes to state whether the claim has been accepted by the employer, if liability has been established, the status of TTD, and the agreement or issuance of a PPD award, alongside the provision for attaching additional pertinent documentation and detailing the nature of the dispute, underscores the exhaustive approach adopted for dispute resolution in workers' compensation cases post-injuries occurring on or after January 1, 2004.

QuestionAnswer
Form NameForm Dwc Ad 10133 55
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other names10133_55Form_ Final dwc ad 1013355 instructions form

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DWC-AD 10133.55

 

Has employer accepted this claim?

 

DWC Use Only

Request for Dispute Resolution

 

___ Yes

 

___ No

 

 

 

Has liability for injury been found by the WCAB?

 

 

Before the Administrative

 

___ Yes

 

___ No

 

 

 

 

Director

Has it been more than 60 days since TTD ended?

 

 

 

 

___ Yes

 

___ No

 

 

 

(For injuries occurring on or after

 

 

 

 

 

Has PPD award been stipulated, issued/approved?

 

 

 

1/1/04)

 

 

___ Yes

 

___ No

 

 

 

 

 

 

 

 

 

 

 

 

___Original

___Response

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Social Security Number

 

WCAB Number

 

 

 

 

DWC Unit Number

 

 

 

 

 

 

 

 

 

 

Employee Name

(Last)

(First)

 

(MI)

Phone

 

Date of Birth

 

 

 

 

 

 

 

 

 

 

Address

(Street)

 

(City)

 

 

(State)

 

(Zip)

 

 

 

 

 

 

 

Employer Name

 

 

 

Phone

 

Insurance Company Name; Or, if Self-Insured, Certificate Name

 

 

 

 

 

 

 

Address

 

 

 

 

 

Adjusting Agency Name (if adjusted)

 

 

 

 

 

 

 

 

 

City, State, Zip

 

 

 

 

 

Claims Mailing Address

 

 

 

 

 

 

 

 

 

Date of Injury

 

Claim Number

 

City, State, Zip

 

Phone No.

 

 

 

 

 

 

 

 

Employee Representative (if any)

 

 

 

Employer Representative

 

 

 

 

 

 

 

 

 

 

 

 

Firm Name

 

 

 

 

 

Firm Name

 

 

 

 

 

 

 

 

 

 

 

 

 

Address

 

 

 

 

 

Address

 

 

 

 

 

 

 

 

 

 

 

 

City, State, Zip

 

 

 

Phone No.

 

City, State, Zip

 

Phone No.

 

 

 

 

 

 

 

 

 

 

Vocational & Return to Work Counselor (if applicable)

 

 

Firm Name

 

 

 

 

Representative Name

 

 

 

 

 

 

 

 

 

 

Address (Street, City, State, Zip

 

 

 

 

 

 

Phone No.

 

 

 

 

 

 

 

 

 

 

The Administrative Director is requested to resolve the following dispute because the parties disagree on: (Please describe and attach all pertinent documents)

Summary of Parties' Informal Efforts to Resolve this Dispute

Proof of Service: I declare under penalty of perjury under the laws of the

.

 

State of California that on the date written below, I mailed a copy of this

 

 

request with a copy of any documents included with this request to the

 

 

following parties at the following addresses:

 

 

 

Administrative Director, (SJDB), Division of Workers’ Compensation,

 

 

P.O. Box 420603, San Francisco, CA 94102-3660

 

 

 

 

 

Name of Requester

Date

Signature

Date

 

 

 

 

(Mandatory Form DWC-AD 10133.55 08/05)

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