Fill and Sign the Dwc Ca Form 10297 Arbitration Submittal Dir

State of California Division of Workers' Compensation Workers' Compensation Appeals Board Arbitration Submittal Form Address/P.O. Box: City: State: Zip Code: Last Name: First Name: Middle Initial: Employee Employee Representative Law Firm /Attorney Non attorney Representative Law Firm: Last Name: First Name: Middle Initial: Address/P.O.Box: City: State: Zip Code: Party Requesting Arbitration (If applicable) Party Name: Address: City: State: Zip Code: DWC-CA form 10297 Rev: 11/2008 Page 1 of 4 Case number: List all the parties to this request for arbitration in the spaces provi\ ded below. Address/P.O.Box: Zip Code: State: City: Last Name: Middle Initial First Name: Law Firm: Party Representative Is the injured worker requesting arbitration or is the injured worker a \ party to the arbitration? Insurance Co. Self-Insured Legally Uninsured Uninsured Lien Claimant Party to the Arbitration Zip Code: State: City: Address: Party Name: Middle Initial: Zip Code: State: City: Address/P.O.Box: Last Name: First Name: Law Firm : Law Firm /Attorney Non attorney Representative Party Representative DWC-CA form 10297 Rev: 11/2008 Page 2 of 4 Case Number: Zip Code: State: City: Address/P.O.Box: Last Name: Middle Initial: First Name: Law Firm: Law Firm /Attorney Non attorney Representative Party Representative Zip Code: State: City: Address: Party Name: Case Number: Party to the Arbitration Insurance Co. Self-Insured Legally Uninsured Uninsured Lien Claimant Insurance Co. Self-Insured Legally Uninsured Uninsured Lien Claimant Zip Code: State: City: Address/P.O.Box: Last Name: Middle Initial: First Name: Law Firm : Law Firm /Attorney Non attorney Representative Party Representative Zip Code: State: City: Address: Party Name: Party to the Arbitration DWC-CA form 10297 Rev: 11/2008 Page 3 of 4 Case Number: Zip Code: State: City: Address/P.O.Box: First Name: Middle Initial: Last Name: Law Firm : Law Firm /Attorney Non attorney Representative Party Representative Zip Code: State: City: Address: Party Name: Case Number: Party to the Arbitration Insurance Co. Self-Insured Legally Uninsured Uninsured Lien Claimant Insurance Co. Self-Insured Legally Uninsured Uninsured Lien Claimant The issues below are hereby submitted for arbitration pursuant to Labor \ Code section 5275: Mandatory arbitration under Labor Code section 5275 (a) Insurance Coverage Contribution Voluntary arbitration under Labor Code section 5275 (b) Explanation of issues submitted for arbitration The parties have agreed to have this case heard before: Arbitrator Name Address: City: State: Zip Code: Phone Number: The parties have unsuccessfully attempted to agree on a arbitrator and r\ equest a list of arbitrators pursuant to Labor Code section 5271(b). at Party or party representative: Party or party representative: Party or party representative: DWC-CA form 10297 Rev: 11/2008 Page 4 of 4 Party or party representative: , Party or party representative: The parties to the arbitration must sign this form in the spaces provide\ s below. Dated: