Form Dwc-Ad 10133.53 - Notice Of Offer Of Modified Or Alternative Work - State Of California

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State of California
Division of Workers' Compensation
NOTICE OF OFFER OF MODIFIED OR ALTERNATIVE WORK
FOR INJURIES OCCURRING BETWEEN 1/1/04 - 12/31/12, INCLUSIVE
DWC - AD 10133.53
THIS SECTION COMPLETED BY CLAIMS ADMINISTRATOR (All information in this section must be completed):
Claims Administrator Type: (Please Choose One)
Third Party Administrator
Employer
Insurance Company
Employer Name
is offering you
(Employee Name)
the position of a
.
Job Title
You may contact
concerning this offer. Phone No.:
Date of offer:
Date job starts:
MM/DD/YYYY
MM/DD/YYYY
Claims Administrator
Claim Number :
NOTICE TO EMPLOYEE (All information in this section must be completed)
Name of employee:
First Name
Last Name
(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)
Date offer received:
Date of Birth:
MM/DD/YYYY
MM/DD/YYYY
You have 30 calendar days from receipt to accept or reject the attached offer of modified or alternative work. Regardless
of whether you accept or reject this offer, the remainder of your permanent disability payments may be decreased by 15%.
However, if you fail to respond in 30 days or reject this job offer, you will not be entitled to the supplemental job
displacement benefit unless:
Modified Work
or Alternative Work
A. You cannot perform the essential functions of the job; or
B. The job is not a regular position lasting at least 12 months; or
C. Wages and compensation offered are less than 85% paid at the time of injury; or
D. The job is beyond a reasonable commuting distance from residence at time of injury.
DWC-AD form 10133.53 (SJDB) Rev: 1/1/14 Page 1 of 4

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