Workers' Compensation Appeals Board
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6STATE OF CALIFORNIA
DEPARTMENT OF INDUSTRIAL RELATIONS
WORKERS’ COMPENSATION APPEALS BOARD
.
CASE NO
APPLICANT
.
V
-
§5502 (e) (3)
(
).
PRE
TRIAL CONFERENCE STATEMENT
DEFENDANT
S
�
NOTICE OF HEARING
:
:
:
LOCATION
DATE
TIME
:
SETTLEMENT CONFERENCE JUDGE
:
APPEARANCES
:
�
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
DEFENDANT
:
�
OTHERS APPEARING
(
.
.,
,
.)
L
C
INTERPRETERS
ETC
:
�
ADDRESS RECORD CHANGES
’
BOX BELOW TO BE COMPLETED ONLY BY WORKERS
COMPENSATION JUDGE
:
�
WCAB NOTICE
�
NOTICE WAIVED
:
DISPOSITION
SET FOR REGULAR HEARING
1
2
½
�
HOUR
�
HOURS
DAY
ALL DAY
�
BEFORE ANY WCJ
�
BEFORE WCJ
�
BEFORE ANY WCJ OTHER THAN
(
)
�
CASE
S
SET ON
AT
WCJ
IN
(
)
(
)
(
)
DATE
TIME
LOCATION
:
�
OTHER DISPOSITION AND ORDERS
4
SERVICE AS ORDERED ON PAGE
’
WORKERS
COMPENSATION
ADMINISTRATIVE LAW JUDGE
DWC CA form 10253.1 (Rev 9/2010)
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