Request For Dispute Resolution Before Administrative Director - State Of California

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State of California
Division of Workers' Compensation
REQUEST FOR DISPUTE RESOLUTION
BEFORE ADMINISTRATIVE DIRECTOR
DWC - AD 10133.55
Original
Response
Employer Accepted Claim
Liability found by WCAB
More than 60 Days Since TTD Ended
Claim Number
Has PPD been stipulated, issued/ approved
Case Number
SSN (Numbers Only)
Employee (All information in this section must be completed)
First Name
MI
Last Name
Street Address /PO Box (Please leave blank spaces between numbers, names or words)
City
State
Zip Code
DOB
Phone
MM/DD/YYYY
(Choose only one)
a specific injury on
MM/DD/YYYY
and ended on
a cumulative trauma injury which began on
(START DATE: MM/DD/YYYY)
(END DATE: MM/DD/YYYY)
DWC-AD form 10133.55 (SJDB) Rev: 1/1/14 - Page 1 of 4

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