Form Dwc Ad 10133 55 PDF Details

This is a form to request a determination of whether an activity or proposed activity is water dependent, water reliant or Neither waterdependent nor reliant. The completed form and all required attachments must be submitted at least 45 days before the date on which the determination is requested. Requestors should carefully read instructions and Definitions section for specific information about what constitutes a water-dependent, water-reliant, or neither activity prior to completing this form. In addition to the completed Form Dwc Ad 10133 55, please submit all applicable attachments, including site location map(s), photographs and/or drawings demonstrating the connection of the proposed activity to waters of the state. Please direct any questions you may have concerning this form to the Watershed Section at 360-407-6185. Thank you for your interest in protecting Washington's waters! Bogs are wetlands that are home to many different species of plants and animals. They are valuab

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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