STATE OF CALIFORNIA
DEPARTMENT OF INDUSTRIAL RELATIONS
WORKERS' COMPENSATION APPEALS BOARD
CASE NO. APPLICANT V.
DEFENDANT(S).
PRE-TRIAL CONFERENCE STATEMENT §5502 NOTICE OF HEARING TIME:
(d) (3)
LOCATION: SETTLEMENT CONFERENCE JUDGE: APPEARANCES:
DATE:
INJURED WORKER: INJURED WORKER'S ATTORNEY
ATTY HRG REP
(FIRM NAME AND PERSON APPEARING)
DEFENDANT'S ATTORNEY
ATTY HRG REP ATTY HRG REP ATTY HRG REP ATTY HRG REP
(FIRM NAME AND PERSON APPEARING)
OTHERS APPEARING: (L.C., INTERPRETERS, ETC.) ADDRESS RECORD CHANGES:
(DEFENDANT)
BOX BELOW TO BE COMPLETED ONLY BY WORKERS' COMPENSATION JUDGE
DISPOSITION: SET FOR REGULAR HEARING:
1 HOUR 2 HOURS ½ DAY BEFORE ANY WCJ BEFORE WCJ CASE(S) SET ON AT (DATE) (TIME)
ALL DAY
WCAB NOTICE
NOTICE WAIVED
BEFORE ANY WCJ OTHER THAN
WCJ IN
(LOCATION)
OTHER DISPOSITION AND ORDERS:
SERVICE AS ORDERED ON PAGE 4 WORKERS' COMPENSATION ADMINISTRATIVE LAW JUDGE
DWC CA form 10253.1 (Rev 11/2008)
PRE-TRIAL CONFERENCE STATEMENT
CASE NO.
STIPULATIONS
THE FOLLOWING FACTS ARE ADMITTED:
1.
WHILE
, BORN ____/____/____
EMPLOYED ALLEGEDLY EMPLOYED
ON DURING THE PERIOD(S)
AS A(N) AT BY
,
OCCUPATIONAL GROUP NUMBER
,
CALIFORNIA,
SUSTAINED INJURY ARISING OUT OF AND IN THE COURSE OF EMPLOYMENT TO
CLAIMS TO HAVE SUSTAINED INJURY ARISING OUT OF AND IN THE COURSE OF EMPLOYMENT TO
2.
AT THE TIME OF INJURY THE EMPLOYER'S WORKERS' COMPENSATION CARRIER WAS
THE EMPLOYER WAS
PERMISSIBLY SELF-INSURED
UNINSURED
LEGALLY UNINSURED
PER WEEK, WARRANTING INDEMNITY FOR PERMANENT DISABILITY.
3.
AT THE TIME OF INJURY, THE EMPLOYEE'S EARNINGS WERE $ RATES OF $ FOR TEMPORARY DISABILITY AND $
4.
THE CARRIER/EMPLOYER HAS PAID COMPENSATION AS FOLLOWS: WEEKLY RATE PERIOD
(TD/PD/VRMA)
TYPE WEEKLY RATE PERIOD
TYPE
THE EMPLOYEE HAS BEEN ADEQUATELY COMPENSATED FOR ALL PERIODS OF T/D CLAIMED THROUGH
5.
THE EMPLOYER HAS FURNISHED
ALL
SOME
NO MEDICAL TREATMENT.
THE PRIMARY TREATING PHYSICIAN IS
6. 7.
NO ATTORNEY FEES HAVE BEEN PAID AND NO ATTORNEY FEE ARRANGEMENTS HAVE BEEN MADE. OTHER STIPULATIONS
APPLICANT
DEFENDANT
LIEN CLAIMANT/OTHER
PAGE 2
DWC CA form 10253.1 (Rev 11/2008)
PRE-TRIAL CONFERENCE STATEMENT ISSUES
EMPLOYMENT INSURANCE COVERAGE INJURY ARISING OUT OF AND IN THE COURSE OF EMPLOYMENT PARTS OF BODY INJURED: EARNINGS: EMPLOYEE CLAIMS
EMPLOYER/CARRIER CLAIMS
CASE NO.
PER WEEK, BASED ON PER WEEK, BASED ON
TEMPORARY DISABILITY, EMPLOYEE CLAIMING THE FOLLOWING PERIOD(S):
PERMANENT AND STATIONARY DATE:
EMPLOYEE CLAIMS ____/____/____, BASED ON EMPLOYER/CARRIER CLAIMS ____/____/____, BASED ON
PERMANENT DISABILITY
APPORTIONMENT
OCCUPATION AND GROUP NUMBER CLAIMED: BY EMPLOYEE BY EMPLOYER/CARRIER
NEED FOR FURTHER MEDICAL TREATMENT LIABILITY FOR SELF-PROCURED MEDICAL TREATMENT
LIENS:
LIEN CLAIMANT TYPE OF LIEN AMOUNT AND PERIODS PAID
ATTORNEY FEES OTHER ISSUES:
APPLICANT
DEFENDANT
LIEN CLAIMANT/OTHER
PAGE 3
DWC CA form 10253.1 (Rev 11/2008)
PRE-TRIAL CONFERENCE STATEMENT
THIS PAGE FOR JUDGE'S USE ONLY
CASE NO.
___________________
JUDGE'S CONFERENCE NOTES:
ORDERS
IT IS ORDERED PURSUANT TO WCAB RULE 10500, THAT DEFENDANT
FORTHWITH THIS
APPLICANT
LIEN CLAIMANT SERVE
PRE-TRIAL CONFERENCE STATEMENT
NOTICE OF HEARING ON ALL PARTIES OR THEIR REPRESENTATIVE
SHOWN ON THE OFFICIAL ADDRESS RECORD AND ANY ADDITIONAL LIEN CLAIMANTS WHOSE LIENS ARE SHOWN UNDER ISSUES (PAGE
3).
IT IS FURTHER ORDERED THAT DEFENDANT APPLICANT LIEN CLAIMANT SERVE TIMELY NOTICE OF THE TIME AND
PLACE OF ALL REGULAR HEARING SESSIONS ON ALL LIEN CLAIMANTS WHOSE LIENS ARE SHOWN UNDER ISSUES, TOGETHER WITH THE FOLLOWING NOTICE: YOUR LIEN IS AT ISSUE AND WILL BE ADJUDICATED AT REGULAR HEARING.
IT IS FURTHER ORDERED THAT THE PROOF OF SERVICE ORDERED ABOVE BE FILED WITH THE WCAB ONLY ON REQUEST OF THE ASSIGNED WORKERS' COMPENSATION JUDGE.
OTHER DISPOSITION AND ORDERS
SERVICE OF THIS DOCUMENT WAS MADE PERSONALLY UPON
BY WCJ.
DATE _____/_____/_____ WORKERS' COMPENSATION ADMINISTRATIVE LAW JUDGE
PAGE 4
DWC CA form 10253.1 (Rev 11/2008)
PRE-TRIAL CONFERENCE STATEMENT
CASE NO.
EXHIBITS
APPLICANT DEFENDANT LIEN CLAIMANT APPEALS BOARD
DESCRIPTION
DATE
W ITNESSES
ABOVE LISTINGS OF EXHIBITS AND WITNESSES REVIEWED BY ALL PARTIES.
APPLICANT PAGE ___ OF ___
DEFENDANT
LIEN CLAIMANT/OTHER
DWC CA form 10253.1 (Rev 11/2008)
PRE-TRIAL CONFERENCE STATEMENT (MULTIPLE PARTIES)
CASE NO(S)
1.
APPLICANT, BORN
, (1)
SUSTAINED OR CLAIMS INJURY AS FOLLOWS:
(2)
(3)
(4)
CASE NO. DOI CLAIMS ADMITTED BODY PARTS JOB TITLE(S) OCCUPATIONAL GROUP NO(S). EARNINGS & TD/PD RATES EMPLOYER CARRIER ADJUSTED BY WORK COMP SECURED BY COVERAGE DATES INSURED SELF-INSURED UNINSURED
CLAIMS ADMITTED
CLAIMS ADMITTED
CLAIMS ADMITTED
INSURED SELF-INSURED UNINSURED
INSURED SELF-INSURED UNINSURED
INSURED SELF-INSURED UNINSURED
2.
THE CARRIER/EMPLOYER HAS PAID COMPENSATION AS FOLLOWS: TYPE WEEKLY RATE PERIOD PAID BY
3.
THE EMPLOYEE HAS BEEN ADEQUATELY COMPENSATED FOR ALL PERIODS OF TEMPORARY DISABILITY CLAIMED . THROUGH SOME NO MEDICAL TREATMENT.
4.
THE EMPLOYER HAS FURNISHED ALL THE PRIMARY TREATING PHYSICIAN IS
.
5. 6.
NO ATTORNEY FEES HAVE BEEN PAID AND NO ATTORNEY FEE AGREEMENTS HAVE BEEN MADE. OTHER STIPULATIONS:
PAGE _____
DWC CA form 10253.1 (Rev 11/2008)