Free DWC-AD form 10120 (SJDB) - California

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State of California Division of Workers' Compensation Retraining and Return to Work Unit Request for Reimbursement of Accommodation Expenses For injuries on or after July 1, 2004 DWC - AD 10120
Employer (All information in this section must be completed)

Name

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

City

State

Zip Code

Phone Employee Information

Employee First Name

Employee Last Name

Claim Number

Job Title (at the time of injury)

Job Duties (attach job description if available):

(Choose only one)

Date of Birth: MM/DD/YYYY

a specific injury on

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 10120 (SJDB) Rev: 11/2008 - (Page 1)

AD10120

Reimbursement is requested for expenses to accommodate a: (Please Select One) temporarily disabled employee ($1250 maximum) permanently disabled employee ($2500 maximum) Employee's work restrictions and accommodation required (attach treating physician's, QME or AME report, if not previously filed):

Itemized list of costs for which reimbursement is requested (attach all receipts): 1. Modification to work site (list all work done and total cost)

Cost

2. Equipment, furniture and/or tools (list each item and cost)

Cost

3. Any other accommodation expenses:

Cost

(Attach additional sheets if necessary)

DWC-AD form 10120 (SJDB) Rev: 11/2008 - (Page 2)

AD10120

Total Costs: The above costs have not been paid for and are not covered by the insurance carrier or any other source. I declare that the information I have provided on this form is true and correct under penalty of perjury. Date

(Signature of employer or employer's representative)

MM/DD/YYYY

DWC-AD form 10120 (SJDB) Rev: 11/2008 - (Page 3)

AD10120