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STATE OF CALIFORNIA DIVISION OF WORKERS' COMPENSATION WORKERS' COMPENSATION APPEALS BOARD STIPULATIONS WITH REQUEST FOR AWARD (Death Case) DWC-CA form 10214 (b) (Page 1) (REV. 11/2008) Adult Dependent #1 Information Adult Dependent #2 Information Venue Choice is based upon: (Completion of this section is required) Select 3 Letter Office Code For Place/Venue of Hearing (From the Docum\ ent Cover Sheet) DWC-CA form 10214 (b) Case Number 1 Case Number 2 Zip Code City Address/PO Box (Please leave blank spaces between numbers, names or wor\ ds) Last Name First Name MI County of residence of employee (Labor Code section 5501.5(a)(1) or\ (d).) County where injury occurred (Labor Code section 5501.5(a)(2) or (\ d).) County of principal place of business of employee’s attorney (Labor \ Code section 5501.5(a)(3) or (d).) Zip Code MI City Address/PO Box (Please leave blank spaces between numbers, names or wor\ ds) Last Name First Name State State Adult Dependent #3 Information Claims Administrator Information (if known and if applicable) Insurance Carrier Information (if known and if applicable - include eve\ n if carrier is adjusted by claims administrator) Employer Information (Completion of this section is required) DWC-CA form 10214 (b) (Page 2) (REV. 11/2008) DWC-CA form 10214 (b) Zip Code City Address/PO Box (Please leave blank spaces between numbers, names or wor\ ds) MI Last Name First Name Zip Code City Employer Street Address/PO Box (Please leave blank spaces between numbe\ rs, names or words) Employer Name (Please leave blank spaces between numbers, names or word\ s) Insured Self-Insured Legally Uninsured Uninsured Zip Code State City Insurance Carrier Street Address/PO Box (Please leave blank spaces betw\ een numbers, names or words) Insurance Carrier Name (Please leave blank spaces between numbers, name\ s or words) Zip Code State City Street Address/PO Box (Please leave blank spaces between numbers, names\ or words) Name (Please leave blank spaces between numbers, names or words) State State 2. That said employee left surviving him/her, wholly dependent/partially\ dependent, dependents listed herein: (Give name and if a minor, date of birth and relationship to the employee. Adult depend\ ents are listed above and minor dependents are listed below.) Minor dependents Minor Dependent # 4 Information Minor Dependent # 5 Information Minor Dependent # 6 Information \ \ , and both the employer and the employee were subject to the provisions of the Labor Code of th\ e State of California. said employee on . by on while employed at as a That at said time, employer's workers' compensation insurance carrier The parties to the above-entitled action hereby enter into the following\ stipulations and request the Division of Workers' Compensation to issue Findings and Award forthwith, without further proc\ eedings. IT IS HEREBY STIPULATED AS FOLLOWS: , (Years) 1. That DWC-CA form 10214 (b)(Page 3) (REV. 11/2008) DWC-CA form 10214 (b) (Last Name) (First Name) age (Place of injury) (Occupation) (Name of employer; an individual, co-partnership or corporation) covering said injury was Minor dependents? Minor Date of Birth: MM/DD/YYYY Name Relation Minor Minor Name Date of Birth: MM/DD/YYYY Date of Birth: MM/DD/YYYY Relation Name (Date of Death: MM/DD/YYYY) (Date of injury: MM/ DD/YYYY) , sustained injury arising out of and occurring in the course of his/her e\ mployment, proximately resulting in the death of Relation 5. That all necessary medical, surgical and hospital expenses on account\ of said injury has been paid by defendants. (If not paid, explain):on account of death benefit, for which they request credit. 7. It is necessary that a guardian ad litem and trustee be appointed for\ the minors, and the parties request that be appointed such guardian ad litem and trustee. The Workers' Compensation Administrative Law Judge may assume that no at\ torney fee is involved in the above-entitled matter and should the facts be otherwise a detailed explanation shall be\ attached to these stipulations. a week. (State weekly or monthly wages) DWC-CA form 10214 (b) (Page 4) (REV. 11/2008) Total Sum Paid Total Death Benefits Paid DWC-CA form 10214 (b) has previously been paid to 4. That the sum of $ , payable at $ 3. That the said dependents are entitled to a death benefit of $ is payable to on account of the burial expense. The sum of $ Yes No 6. That defendants have heretofore paid the sum of $ Last Name First name based upon earnings of $ (Date) (Date) (Date) Dependent or guardian signature Dependent or guardian signature Dependent or guardian signature Defendant's Attorney or Authorized Representative: Defense Attorney Signature MM/DD/YYYY MM/DD/YYYY Applicant's Attorney or Authorized Representative: Applicant Attorney Signature DWC-CA form 10214 (b) (Page 5) (REV.11/2008) DWC-CA form 10214 (b) Law Firm/Attorney Non Attorney Representative Zip Code City Law Firm Name Law Firm Number Last Name First Name State First Name Last Name Law Firm Number Law Firm Name Zip Code City State (Address/PO Box (Please leave blank spaces between numbers, names or w\ ords) (Address/PO Box (Please leave blank spaces between numbers, names or w\ ords) Dated Dated Law Firm/Attorney Non Attorney Representative