Free DWC-CA form 10297 - California

State of California Division of Workers' Compensation Workers' Compensation Appeals Board Arbitration Submittal Form
Employee First Name: Last Name: Address/P.O. Box: City: Employee Representative Law Firm: First Name: Last Name: Address/P.O.Box: City: State: Zip Code: Law Firm /Attorney State: Zip Code:

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Middle Initial:

Non attorney Representative

Middle Initial:

Is the injured worker requesting arbitration or is the injured worker a party to the arbitration? List all the parties to this request for arbitration in the spaces provided below. Party Requesting Arbitration (If applicable) Insurance Co. Self-Insured Legally Uninsured Uninsured Lien Claimant Case number:

Party Name: Address: City: State: Zip Code:

Party Representative Law Firm: First Name: Last Name: Address/P.O.Box: City: State: Zip Code: Middle Initial

DWC-CA form 10297 Rev: 11/2008 Page 1 of 4

Party to the Arbitration Insurance Co. Self-Insured Legally Uninsured Uninsured Lien Claimant Case Number:

Party Name: Address: City: Party Representative Law Firm: First Name: Last Name: Address/P.O.Box: City: State: Zip Code: Middle Initial: Law Firm /Attorney State: Zip Code:

Non attorney Representative

Party to the Arbitration Insurance Co. Self-Insured Party Name: Address: City:

Legally Uninsured

Uninsured

Lien Claimant Case Number:

State:

Zip Code:

Party Representative Law Firm: First Name: Last Name: Address/P.O.Box: City:

Law Firm /Attorney

Non attorney Representative

Middle Initial:

State:

Zip Code:

DWC-CA form 10297 Rev: 11/2008 Page 2 of 4

Party to the Arbitration Insurance Co. Self-Insured Legally Uninsured Uninsured Lien Claimant Case Number:

Party Name: Address: City: Party Representative Law Firm : First Name: Last Name: Address/P.O.Box: City: State: Zip Code: Middle Initial: Law Firm /Attorney State: Zip Code:

Non attorney Representative

Party to the Arbitration Insurance Co. Self-Insured Legally Uninsured Uninsured Lien Claimant Case Number:

Party Name: Address: City: State: Zip Code:

Party Representative Law Firm: First Name: Last Name: Address/P.O.Box: City:

Law Firm /Attorney

Non attorney Representative

Middle Initial:

State:

Zip Code:

DWC-CA form 10297 Rev: 11/2008 Page 3 of 4

The issues below are hereby submitted for arbitration pursuant to Labor Code section 5275: Mandatory arbitration under Labor Code section 5275 (a) Insurance Coverage Contribution Voluntary arbitration under Labor Code section 5275 (b) Explanation of issues submitted for arbitration

The parties have agreed to have this case heard before: Arbitrator Name Address: City: Phone Number: The parties have unsuccessfully attempted to agree on a arbitrator and request a list of arbitrators pursuant to Labor Code section 5271(b). The parties to the arbitration must sign this form in the spaces provides below. Dated: Party or party representative: Party or party representative: Party or party representative: Party or party representative: Party or party representative: DWC-CA form 10297 Rev: 11/2008 Page 4 of 4 at , State: Zip Code: