Free I&A guide 11 - California

Information & Assistance Unit guide 11

How to file a petition to reopen
If your disability has gotten worse after a workers' compensation judge has issued an award, this form can be used to reopen your case. You should get a medical report from your doctor saying your condition has worsened, and collect any other facts that support your case. Complete the form, following the attached sample. Be sure to sign and date the form. You have five years from the date of injury to file this petition. If the insurance company won't voluntarily reopen your case and you are ready for a hearing, fill out a declaration of readiness to proceed (see I&A guide 5) and submit it with your petition. Mail the original forms to your local district office. Send a copy to the insurance company handling your claim. Keep a copy for your records. Submit the following documents with your form filing in the order shown: Document Cover Sheet Document Separator Sheet (for Petition for Reopen) Petition for Reopen Document Separator Sheet (for Proof of Service By Mail) Proof of Service By Mail All documents filed with the WCAB must include a document cover sheet and document separator sheet. Please see I&A guides 17 and 18 to learn how to complete these forms. In addition all forms must be typed or handwritten in block letters to insure legibility. Additional form instructions can be found on the EAMS OCR handbook at http://www.dir.ca.gov/dwc/eams/SampleFiles/EAMS_OCR%20handbook.pdf. If you need help, call an Information and Assistance (I&A) office, or attend a workshop for injured workers. The local I&A phone numbers are attached to this guide. You can get information on a local workshop from the I&A office or on the Web at www.dwc.ca.gov. If you do not have the name and address of your insurance company to complete a form, please link to http://www.dir.ca.gov/DWC/EAMS/EAMSLC/EAMSClaimsAdmins.asp.

I&A 11 Rev. 5/09

Information & Assistance Unit guide 11
The information contained in this guide is general in nature and is not intended as a substitute for legal advice. Changes in the law or the specific facts of your case may result in legal interpretations different than those present here. When sending documents to a district office, please make sure they are not folded or stapled. Send them in a large manila envelope. Please see the EAMS OCR forms handbook for further instructions.

I&A 11 Rev. 5/09

WORKERS' COMPENSATION APPEALS BOARD DISTRICT OFFICES

ANAHEIM, 92806 1065 N. PacifiCenter Dr., Suite 202 Information & Assistance Unit (714) 414-7401 BAKERSFIELD, 93301-1929 1800 30th Street, Suite 100 Information & Assistance Unit (661) 395-2514 EUREKA, 95501-0481 100 "H" Street, Suite 202 Information & Assistance Unit (707) 441-5723 FRESNO, 93721-2280 2550 Mariposa Street, Suite 4078 Information & Assistance Unit (559) 445-5355 GOLETA, 93117-3018 6755 Hollister Avenue, Suite 100 Information & Assistance Unit (805) 968-4158 GROVER BEACH, 93433-2261 1562 W. Grand Avenue Information & Assistance Unit (805) 481-3380 LONG BEACH, 90802-4339 300 Oceangate Street, Suite 200 Information & Assistance Unit (562) 590-5240 LOS ANGELES, 90013-1105 320 West 4th Street, 9th Floor Information & Assistance Unit (213) 576-7389 MARINA DEL REY, CA 90292 4720 Lincoln Blvd. 2nd and 3rd floors Information & Assistance Unit (310) 482-3858 OAKLAND, 94612-1402 1515 Clay Street, 6th Floor Information & Assistance Unit (510) 622-2861 OXNARD, 93030 2220 East Gonzales Road, Suite 100 Information & Assistance Unit (805) 485-3528 POMONA, 91766-1601

REDDING, 96001-2796 2115 Civic Center Drive, Suite 15 Information & Assistance Unit (530) 225-2047 RIVERSIDE, 92501-3337 3737 Main Street, Suite 300 Information & Assistance Unit (951) 782-4347 SACRAMENTO, 95825-2403 2424 Arden Way, Suite 230 Information & Assistance Unit (916) 263-2741 SALINAS, 93906-2204 1880 North Main Street, Suites 100 & 200 Information & Assistance (831) 443-3058 SAN BERNARDINO, 92401-1411 464 West Fourth Street, Suite 239 Information & Assistance Unit (909) 383-4522 SAN DIEGO, 92108 7575 Metropolitan Drive, Suite 202 Information & Assistance Unit (619) 767-2082 SAN FRANCISCO, 94102-7002 455 Golden Gate Avenue, 2nd Floor Information & Assistance Unit (415) 703-5020 SAN JOSE, 95113-1482 100 Paseo de San Antonio, Suite 241 Information & Assistance Unit (408) 277-1292 SANTA ANA, 92701-4070 605 W Santa Ana Blvd, Bldg 28, Suite 451 Information & Assistance Unit (714) 558-4597 SANTA ROSA, 95404-4760 50 "D" Streets, Suite 420 Information & Assistance Unit (707) 576-2452 STOCKTON, 94202 31 East Channel Street, Suite 344 Information & Assistance Unit (209) 948-7980 VAN NUYS, 91401-3373 6150 Van Nuys Blvd., Suite 105 Information & Assistance Unit (818) 901-5374

732 Corporate Center Drive
Information & Assistance Unit (909) 623-8568

Rev. 05/09

DOCUMENT SEPARATOR SHEET

Product Delivery Unit

ADJ

Document Type

LEGAL DOCS

Document Title

PETITION TO REOPEN

Document Date

DATE YOU FILLED OUT FORM
MM/DD/YYYY

Author

YOUR NAME

Office Use Only

Received Date MM/DD/YYYY

DWC-CA form 10232.2 Rev. 11/2008 Page 1

SAMPLE
Department of Industrial Relations
Division of Workers' Compensation

WORKERS' COMPENSATION APPEALS BOARD
STATE OF CALIFORNIA
) ) ) Applicant, ) ) ) ) ) ) Defendants )

Case No.

your WCAB case number

Your Name
vs.

PETITION TO REOPEN

Your employer and insurance company

Petitioner hereby requests that the above-entitled action be reopened for the following reasons:

Explain in your words why you feel your case should be reopened

PROOF OF SERVICE (WCAB RULE 10514)

today's date city On _____________ at ___________________
(date) (place)

your signature _____________________________ _ _ _ _ _ _ _ Petitioner

Copy mailed to following addresses:

(1) WCAB _ _________________________________ ___ (2) insurance company _ _________________________________ ___
_ _________________________________ ___

your address _____________________________ _ _ _ _ _ _ _ Address
_____________________________ _ _ _ _ _ _ _ Attorney for Petitioner _____________________________ _ _ _ _ _ _ _ Address of Attorney

your signature _ __________________________
(Signature )

DWC/WCAB FORM 42 (REV. 8-85)

PRINT CLEAR
Department of Industrial Relations
Division of Workers' Compensation

WORKERS' COMPENSATION APPEALS BOARD
STATE OF CALIFORNIA
) ) ) Applicant, ) ) ) ) ) ) Defendants )

Case No.

vs.

PETITION TO REOPEN

Petitioner hereby requests that the above-entitled action be reopened for the following reasons:

PROOF OF SERVICE (WCAB RULE 10514) On _____________ at ___________________
(date) (place)

____________________________________ Petitioner

Copy mailed to following addresses: _____________________________________ ____________________________________ Address ____________________________________ Attorney for Petitioner ____________________________________ Address of Attorney

_____________________________________

_____________________________________

___________________________
(Signature )

DWC/WCAB FORM 42 (REV. 8-85)

PRINT CLEAR

Proof Of Service By Mail I declare that: YOUR COUNTY I am (resident of/employed in) the county of _______________ California. I am over the age of eighteen years, my (business/residence) address is: PUT YOUR HOME ADDRESS HERE __________________________________________________________ __________________________________________________________

NAME OF DOCUMENT On TODAY'S DATE I served the attached _______________________ on the ____________,
INSURANCE COMPANY ________________ in said case, by placing a true copy thereof enclosed in a sealed envelope with postage thereon fully paid, in the United State mail at

CITY WHERE YOU MAILED THIS _______________________________ addressed as follows ____________
__________________________________________________________ __________________________________________________________ I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct, and that this declaration was executed on

TODAY'S DATE ( d a t e ) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ , a t _CITY _ _ _ _ _ _ _ _ _ _ _ C a l i f o r n i a . ____
PRINT YOUR NAME Type or print name _____________________________________
SIGN YOUR NAME Signature ____________________________________________

PRINT CLEAR

Proof Of Service By Mail I declare that: I am (resident of/employed in) the county of _______________ California. I am over the age of eighteen years, my (business/residence) address is: __________________________________________________________ __________________________________________________________ On ____________, I served the attached _______________________ on the ________________ in said case, by placing a true copy thereof enclosed in a sealed envelope with postage thereon fully paid, in the United State mail at _______________________________ addressed as follows ____________ __________________________________________________________ __________________________________________________________ I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct, and that this declaration was executed on (date) ___________________, at ________________ California. Type or print name _____________________________________ Signature ____________________________________________