Request For Dispute Resolution Before Administrative Director - State Of California Page 4
Download a blank fillable Request For Dispute Resolution Before Administrative Director - State Of California in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Request For Dispute Resolution Before Administrative Director - State Of California with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4When there is a dispute regarding the Supplemental Job Displacement Benefit, the employee, or claims administrator
may request the Administrative Director to resolve the dispute.
• Clearly state the issue(s) and identify supporting information for each issue and position.
•
Attach all pertinent documents.
•
Serve copies of the request and all attached documents on all parties.
•
Mail this Request for Dispute Resolution along with all attached documents to: Administrative Director,
Division of Workers' Compensation, P.O. Box 420603, San Francisco, CA 94142-0603.
The opposing party shall have 20 calendar days from the date of the proof of service to submit the original response and
all attached documents to the Administrative Director.
The Administrative Director or his or her designee will issue a written determination within 30 calendar days of the date
of the opposing party's response. If the Administrative Director requests additional information the written determination
will be issued within 30 calendar days from the receipt of the additional information.
In the event no decision is issued within 60 calendar days of the date of the opposing party's response is due or within
60 calendar days of the administrative directors receipt of the requested additional information, whichever is later, the
request will be deemed to be denied.
Either party may appeal the determination of the Administrative Director by filing a written petition together with a
Declaration of Readiness to Proceed (which can be found at:
DWCCAForm10250_1.pdf) within 20 calendar days of the decision or within 20 days after a request is deemed denied.
The petition shall set forth the specific factual and/or legal reasons for the appeal.
PROOF OF SERVICE
On
I served the attached Request for Dispute Resolution on:
,
by placing a true copy thereof enclosed in a sealed envelope with postage thereon fully paid, in the United States mail.
by personal service.
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:
at
CA.
,
Signature:
Print Name:
DWC-AD form 10133.55 (SJDB) Rev: 1/1/14 - Page 4 of 4
ADVERTISEMENT
0 votes
Related Articles
Related forms
Application For Administrator Certification - State Of California - Health And Human Services Agency
Legal
Caeatfa Exemption Certificate For Sales And Use Tax Exclusion - State Of California Board Of Equalization
Financial
64-029 - Application For License To Sell Nursery Stock - State Of California, Department Of Food And Agriculture
Legal
Application For A Child Care Center License - State Of California - Health And Human Services Agency
Legal
San Francisco Business Receipts And Payroll Tax Worksheet For Garment Manufacturers' Tax Credit 2000 - State Of California
Financial
Form Boe-261-g (p1) - Claim For Disabled Veterans' Property Tax Exemption - State Of California - 2013
Financial
Related Categories
Parent category: Legal