Workers' Compensation Appeals Board Page 3
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PRE
TRIAL CONFERENCE STATEMENT
CASE NO
ISSUES
�
EMPLOYMENT
�
INSURANCE COVERAGE
�
INJURY ARISING OUT OF AND IN THE COURSE OF EMPLOYMENT
:
�
PARTS OF BODY INJURED
:
,
�
EARNINGS
EMPLOYEE CLAIMS
PER WEEK
BASED ON
/
,
EMPLOYER
CARRIER CLAIMS
PER WEEK
BASED ON
,
(
):
�
TEMPORARY DISABILITY
EMPLOYEE CLAIMING THE FOLLOWING PERIOD
S
:
�
PERMANENT AND STATIONARY DATE
____/____/____,
EMPLOYEE CLAIMS
BASED ON
/
____/____/____,
EMPLOYER
CARRIER CLAIMS
BASED ON
�
PERMANENT DISABILITY
�
APPORTIONMENT
:
�
OCCUPATION AND GROUP NUMBER CLAIMED
BY EMPLOYEE
/
BY EMPLOYER
CARRIER
�
NEED FOR FURTHER MEDICAL TREATMENT
-
�
LIABILITY FOR SELF
PROCURED MEDICAL TREATMENT
:
�
LIENS
LIEN CLAIMANT
TYPE OF LIEN
AMOUNT AND PERIODS PAID
�
ATTORNEY FEES
:
�
OTHER ISSUES
/
APPLICANT
DEFENDANT
LIEN CLAIMANT
OTHER
P
3
AGE
DWC CA form 10253.1 (Rev 11/2008 9/2010)
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