Free DWC-AD form 10133.55 (SJDB) - California

State of California Division of Workers' Compensation Retraining and Return to Work Unit REQUEST FOR DISPUTE RESOLUTION BEFORE ADMINISTRATIVE DIRECTOR DWC - AD 10133.55
Original Employer Accepted Claim Liability found by WCAB More than 60 Days Since TTD Ended Has PPD been stipulated, issued/ approved Claim Number Response

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SSN (Numbers Only) Employee (All information in this section must be completed)

Case Number

First Name

MI

Last Name

Street Address /PO Box (Please leave blank spaces between numbers, names or words)

City DOB

State

Zip Code

Phone (Choose only one)
a specific injury on

MM/DD/YYYY

MM/DD/YYYY

a cumulative trauma injury which began on

(START DATE: MM/DD/YYYY)

and ended on

(END DATE: MM/DD/YYYY)

DWC-AD form 10133.55 (SJDB) Rev: 11/2008 - ( Page 1)

10133.55

Employee Representative (If Applicable)

Name

Address/PO Box (Please leave blank spaces between numbers, names or words)

City
Phone

State

Zip Code

Employer (All information in this section must be completed) Insured Self-Insured Legally Uninsured Uninsured

Name

Employer Street Address/PO Box (Please leave blank spaces between numbers, names or words)

City

State

Zip Code

Phone Employer Representative (if known and If applicable) Name

Address/PO Box (Please leave blank spaces between numbers, names or words)

City Phone Claims Administrator Information (if known and if applicable)

State

Zip Code

Name (Please leave blank spaces between numbers, names or words)

Street Address/PO Box (Please leave blank spaces between numbers, names or words)

City
DWC-AD form 10133.55(SJDB) Rev: 11/2008 - ( Page 2)

State

Zip Code

10133.55

Vocational & Return to Work Counselor (if applicable)

Name

Firm Name

Address/PO Box (Please leave blank spaces between numbers, names or words)

City Phone

State

Zip Code

Administrative Director Requested to resolve the following dispute because the parties disagree on (All information in this section must be completed): Employee's entitlement to a voucher. The parties dispute the amount of the voucher. The insurer has failed to pay training provider per title 8, California Code of Regulations sections 10133.57 and 10133. 58, and/or the VRTWC per title 8 California Code of Regulations sections 10133.57 and 10133.59. The employee objects to the new job duties provided by the employer. The employer objects to the amount of reimbursement approved or denied. Other

Summary of informal efforts to resolve dispute

Requester Name

Date Signature
DWC-AD form 10133.55(SJDB) Rev: 11/2008 - ( Page 3)

MM/DD/YYYY

10133.55