Workers' Compensation Appeals Board Page 6
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6-
(
)
(
)
PRE
TRIAL CONFERENCE STATEMENT
MULTIPLE PARTIES
CASE NO
S
1.
,
,
:
APPLICANT
BORN
SUSTAINED OR CLAIMS INJURY AS FOLLOWS
(1)
(2)
(3)
(4)
.
CASE NO
DOI
CLAIMS
�
CLAIMS
�
CLAIMS
�
CLAIMS
�
ADMITTED
�
ADMITTED
�
ADMITTED
�
ADMITTED
�
BODY PARTS
(
)
JOB TITLE
S
OCCUPATIONAL
(
).
GROUP NO
S
&
EARNINGS
/
TD
PD RATES
EMPLOYER
CARRIER
ADJUSTED BY
WORK COMP
INSURED
�
INSURED
�
INSURED
�
INSURED
�
-
-
-
-
�
�
�
�
SECURED BY
SELF
INSURED
SELF
INSURED
SELF
INSURED
SELF
INSURED
UNINSURED
�
UNINSURED
�
UNINSURED
�
UNINSURED
�
COVERAGE DATES
2.
/
:
THE CARRIER
EMPLOYER HAS PAID COMPENSATION AS FOLLOWS
TYPE
WEEKLY RATE
PERIOD
PAID BY
3.
�
THE EMPLOYEE HAS BEEN ADEQUATELY COMPENSATED FOR ALL PERIODS OF TEMPORARY DISABILITY CLAIMED
.
THROUGH
4.
.
THE EMPLOYER HAS FURNISHED
�
ALL
�
SOME
�
NO MEDICAL TREATMENT
.
THE PRIMARY TREATING PHYSICIAN IS
5.
.
�
NO ATTORNEY FEES HAVE BEEN PAID AND NO ATTORNEY FEE AGREEMENTS HAVE BEEN MADE
6.
:
�
OTHER STIPULATIONS
P
_____
AGE
DWC CA form 10253.1 (Rev 9/2010)
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