Wcab Form 24 – Fill Out and Use This PDF

STATE OF CALIFORNIA

DIVISION OF WORKERS’ COMPENSATION

WORKERS’ COMPENSATION APPEALS BOARD

PRE-TRIAL CONFERENCE STATEMENT

LOCATION:

DATE:

TIME:

SETTLEMENT CONFERENCE JUDGE:

APPEARANCES

INJURED WORKER:

	INJURED WORKER’S ATTORNEY:				ATTY HRG REP
		(FIRM NAME AND PERSON APPEARING)
	DEFENDANT’S ATTORNEY:					ATTY HRG REP
						ATTY HRG REP
						ATTY HRG REP
						ATTY HRG REP
		(FIRM NAME AND PERSON APPEARING)			(DEFENDANT)

OTHERS APPEARING:

(L.C., INTERPRETERS, ETC.)

ADDRESS RECORD CHANGES:

BOX BELOW TO BE COMPLETED ONLY BY WORKERS’ COMPENSATION JUDGE

DISPOSITION: SET FOR REGULAR HEARING:

 WCAB NOTICE

 NOTICE WAIVED



1 HOUR  2 HOURS

 ½ DAY



ALL DAY

 LIEN TRIAL



BEFORE ANY WCJ  BEFORE WCJ



BEFORE ANY WCJ OTHER THAN



CASE(S) SET ON

AT

WCJ

IN

(DATE)

(TIME)

(LOCATION)

OTHER DISPOSITION AND ORDERS:

SERVICE AS ORDERED ON PAGE 4

WORKERS’ COMPENSATION JUDGE

WCAB FORM 24 (REV. 2013)

PAGE 1 OF ___

STATE OF CALIFORNIA

DIVISION OF WORKERS’ COMPENSATION

WORKERS’ COMPENSATION APPEALS BOARD

PRE-TRIAL CONFERENCE STATEMENTCASE NO. ______________________

		STIPULATIONS
THE FOLLOWING FACTS ARE ADMITTED:
1.		, BORN ______________
WHILE		 EMPLOYED  ALLEGEDLY EMPLOYED

ON

DURING THE PERIOD(S)

AS A(N)			, OCCUPATIONAL GROUP NUMBER
AT			, CALIFORNIA,
BY

SUSTAINED INJURY ARISING OUT OF AND IN THE COURSE OF EMPLOYMENT TO

CLAIMS TO HAVE SUSTAINED INJURY ARISING OUT OF AND IN THE COURSE OF EMPLOYMENT TO

2.AT THE TIME OF INJURY THE EMPLOYER’S WORKERS’ COMPENSATION CARRIER WAS

 THE EMPLOYER WAS		 PERMISSIBLY SELF-INSURED  UNINSURED					 LEGALLY UNINSURED
3. AT THE TIME OF INJURY, THE EMPLOYEE’S EARNINGS WERE $						PER WEEK, WARRANTING INDEMNITY
RATES OF $			FOR TEMPORARY DISABILITY AND $				FOR PERMANENT DISABILITY.

4.THE CARRIER/EMPLOYER HAS PAID COMPENSATION AS FOLLOWS: (TD/PD/VRMA)

TYPE	WEEKLY RATE PERIOD					TYPE		WEEKLY RATE PERIOD

THE EMPLOYEE HAS BEEN ADEQUATELY COMPENSATED FOR ALL PERIODS OF T/D CLAIMED THROUGH

5. THE EMPLOYER HAS FURNISHED  ALL  SOME  NO MEDICAL TREATMENT. THE PRIMARY TREATING PHYSICIAN IS

6. NO ATTORNEY FEES HAVE BEEN PAID AND NO ATTORNEY FEE ARRANGEMENTS HAVE BEEN MADE.

7. OTHER STIPULATIONS

APPLICANT

DEFENDANT

LIEN CLAIMANT/OTHER

WCAB FORM 24 (REV. 2013)

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STATE OF CALIFORNIA

DIVISION OF WORKERS’ COMPENSATION

WORKERS’ COMPENSATION APPEALS BOARD

PRE-TRIAL CONFERENCE STATEMENT

CASE NO. ______________________

ISSUES

EMPLOYMENT:

INSURANCE COVERAGE:

INJURY ARISING OUT OF AND IN THE COURSE OF EMPLOYMENT:

PARTS OF BODY INJURED:

 EARNINGS: EMPLOYEE CLAIMS				PER WEEK, BASED ON
EMPLOYER/CARRIER CLAIMS				PER WEEK, BASED ON

TEMPORARY DISABILITY, EMPLOYEE CLAIMING THE FOLLOWING PERIOD(S):

PERMANENT AND STATIONARY DATE:

EMPLOYEE CLAIMS ______________, BASED ON

EMPLOYER/CARRIER CLAIMS ______________, BASED ON

 PERMANENT DISABILITY  APPORTIONMENT

OCCUPATION AND GROUP NUMBER CLAIMED: BY EMPLOYEE

BY EMPLOYER/CARRIER

NEED FOR FURTHER MEDICAL TREATMENT:

LIABILITY FOR SELF-PROCURED MEDICAL TREATMENT:

LIENS:

LIEN CLAIMANT		TYPE OF LIEN		AMOUNT AND PERIODS PAID

ATTORNEY FEES

OTHER ISSUES:

APPLICANT

DEFENDANT

LIEN CLAIMANT/OTHER

WCAB FORM 24 (REV. 2013)

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STATE OF CALIFORNIA

DIVISION OF WORKERS’ COMPENSATION

WORKERS’ COMPENSATION APPEALS BOARD

PRE-TRIAL CONFERENCE STATEMENT

CASE NO. ______________________

THIS PAGE FOR JUDGE’S USE ONLY

JUDGE’S CONFERENCE NOTES:

ORDERS
 IT IS ORDERED PURSUANT TO WCAB RULE 10500, THAT  DEFENDANT	APPLICANT  LIEN CLAIMANT SERVE
FORTHWITH THIS PRE-TRIAL CONFERENCE STATEMENT  NOTICE OF HEARING	ON ALL PARTIES OR THEIR REPRESENTATIVE

SHOWN ON THE OFFICIAL ADDRESS RECORD AND ANY ADDITIONAL LIEN CLAIMANTS WHOSE LIENS ARE SHOWN UNDER ISSUES (PAGE

3).

 IT IS FURTHER ORDERED THAT  DEFENDANT  APPLICANT  LIEN CLAIMANT SERVE TIMELY NOTICE OF THE TIME

AND PLACE OF ALL REGULAR HEARING SESSIONS ON ALL LIEN CLAIMANTS WHOSE LIENS ARE SHOWN UNDER ISSUES, TOGETHER

WITH THE FOLLOWING NOTICE: YOUR LIEN IS AT ISSUE AND WILL BE ADJUDICATED AT REGULAR HEARING.

IT IS FURTHER ORDERED THAT THE PROOF OF SERVICE ORDERED ABOVE BE FILED WITH THE WCAB ONLY ON REQUEST OF

THE ASSIGNED WORKERS’ COMPENSATION JUDGE.

OTHER DISPOSITION AND ORDERS:

SERVICE OF THIS DOCUMENT WAS MADE PERSONALLY UPON		BY WCJ.

DATE ______________

WORKERS’ COMPENSATION JUDGE

WCAB FORM 24 (REV. 2013)

PAGE 4 OF ___

STATE OF CALIFORNIA

DIVISION OF WORKERS’ COMPENSATION

WORKERS’ COMPENSATION APPEALS BOARD

PRE-TRIAL CONFERENCE STATEMENTCASE NO. ______________________

EXHIBITS

APPLICANT
DEFENDANT
LIEN CLAIMANT		DESCRIPTION		DATE
APPEALS BOARD

WITNESSES

ABOVE LISTINGS OF EXHIBITS AND WITNESSES REVIEWED BY ALL PARTIES.

APPLICANT

DEFENDANT

LIEN CLAIMANT/OTHER

WCAB FORM 24 (REV. 2013)

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