Free DWC-CA form 10252.1 - California

STATE OF CALIFORNIA DIVISION OF WORKERS' COMPENSATION WORKERS' COMPENSATION APPEALS BOARD DECLARATION OF READINESS TO PROCEED TO EXPEDITED HEARING (TRIAL) [Labor Code section 5502(b) ]

Reset Form

Print Form

NOTICE: Any objection to the proceedings requested by a Declaration of Readiness to proceed shall be filed and served within ten (10) days after service of the Declaration.

Case No. Applicant

First Name

MI

Last Name Employer Information

VS

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

The Declarant requests that this case be set for expedited hearing and decision on the following issues: Entitlement to medical treatment per Labor Code section 4600. Entitlement to temporary disability, or disagreement on amount of temporary disability. Appeal from a determination of the Rehabilitation Unit finding entitlement to or terminating liability for rehabilitation services, or enforcement of an order of the Rehabilitation Unit. Entitlement to compensation is in dispute because of a disagreement between employers and/or carriers. Declarant states under penalty of perjury that he or she has made the following specific, genuine, good faith efforts to resolve the dispute(s) listed above:

DWC-CA form 10252.1 Page 1 (Rev. 11/2008)

DWC-CA form 10252.1

Declarant states under penalty of perjury that there is a bona fide dispute; that he/she is presently ready to proceed to hearing; that his/her discovery is complete on said issues. Declarant's Signature

Name of declarant or name of the law firm of the declarant (Print or Type)

Address (Please leave blank spaces between numbers, names or words) Date Phone Number MM/DD/YYYY

DWC-CA form 10252.1 Page 2 (Rev. 11/2008)

DWC-CA form 10252.1