Form Dwc-Ad 10133.53 - Notice Of Offer Of Modified Or Alternative Work
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DWC-AD 10133.53 NOTICE OF OFFER OF MODIFIED OR ALTERNATIVE WORK
For injuries occurring on or after 1/1/04
THIS SECTION COMPLETED BY CLAIMS ADMINISTRATOR:
Employer (name of firm)_________________________________ is offering you the position of a
(name of job) ____________________________________.
You may contact
concerning this offer.
Phone No.:
Date of offer:
Date job starts:
.
Claims Administrator:
Claim Number:
NOTICE TO EMPLOYEE
Name of employee:
Date of Injury:
Date offer received:
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.
THIS SECTION TO BE COMPLETED BY EMPLOYEE
I accept this offer of Modified or Alternative work.
__
I reject this offer of Modified or Alternative work and understand that I am not entitled to the Supplemental Job Displacement
__
Benefit.
I understand that if I voluntarily quit prior to working in this position for 12 months, I may not be entitled to the Supplemental
Job Displacement Benefit.
Date
Signature
I feel I cannot accept this offer because:
NOTICE TO THE PARTIES
If the offer is not accepted or rejected within 30 days of the offer, the offer is deemed to be rejected by the employee.
The employer or claims administrator must forward a completed copy of this agreement to the Administrative Director within 30 days
of acceptance or rejection. (A.D., “SJDB,” Division of Workers’ Compensation, P.O. Box 420603, S.F., CA 94102-3660)
If a dispute occurs regarding the above offer or agreement, either party may request the Administrative Director to resolve the dispute
by filing a Request for Dispute Resolution (Form DWC-AD 10133.55) with the Administrative Director.
MANDATORY FORM (Page 1 of 2)
STATE OF CALIFORNIA
(08/05)
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