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STATE OF CALIFORNIA DIVISION OF WORKERS' COMPENSATION WORKERS' COMPENSATION APPEALS BOARD STIPULATIONS WITH REQUEST FOR AWARD Applicant (Completion of this section is required) MM/DD/YYYY DWC-WCAB form 10214 (a) -1 Page 1 (Rev 4/2014) Venue Choice is based upon: (Completion of this section is required) Select 3 Letter Office Code For Place/Venue of Hearing (From the Docume\ nt Cover Sheet) Employer #1 Information (Completion of this section is required) Case No. Date of Injury SSN (Numbers Only) 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).) MI Zip Code City Address/PO Box (Please leave blank spaces between numbers, names or wor\ ds) First Name Last 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 State State Employer #2 Information (Completion of this section is required) Insurance Carrier Information (if known and if applicable - include eve\ n if carrier is adjusted by claims administrator) Claims Administrator Information (if known and if applicable) Insurance Carrier Information (if known and if applicable - include even if carrier is adjusted by cl\ aims administrator) Zip Code 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) 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 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 DWC-WCAB form 10214 (a) -1 Page 2 (Rev 4/2014) State State Claims Administrator Information (if known and if applicable) Employer #3 Information (Completion of this section is required)Insurance Carrier Information (if known and if applicable - include even if carrier is adjusted by cl\ aims administrator) Claims Administrator Information (if known and if applicable) DWC-WCAB form 10214 (a) -1 Page 3 (Rev 4/2014) 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) 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 Employer #4 Information (Completion of this section is required) The parties hereto stipulate to the issuance of an Award and/or Order, b\ ased upon the following facts, and waive the requirements of Labor Code section 5313: , as a(n) while employed at , , MM/DD/YYYY Insurance Carrier Information (if known and if applicable - include even if carrier is adjusted by cl\ aims administrator) Claims Administrator Information (if known and if applicable) DWC-WCAB form 10214 (a) -1 Page 4 (Rev 4/2014) 1. , birth date Occupation Group 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) Employees Last Name Employees First Name in State State (If Specific Injury, use the start date as the specific date of injury)\ (If Specific Injury, use the start date as the specific date of injury)\ by the employer(s) and their insurer(s) listed above and who sustain\ ed injury(ies) arising out of and in the course of employment to (If Specific Injury, use the start date as the specific date of injury)\ (If Specific Injury, use the start date as the specific date of injury)\ DWC-WCAB form 10214 (a) -1 Page 5 (Rev 4/2014) More than 4 Companion Cases Specific Injury Cumulative Injury Specific Injury Cumulative Injury Specific Injury Cumulative Injury Specific Injury Cumulative Injury (Please list all body parts injured) (End Date: MM/DD/YYYY) (Start Date: MM/DD/YYYY) Case Number 1 (End Date: MM/DD/YYYY) (Start Date: MM/DD/YYYY) Case Number 2 (End Date: MM/DD/YYYY) (Start Date: MM/DD/YYYY) Case Number 3 (End Date: MM/DD/YYYY) (Start Date: MM/DD/YYYY) Case Number 4 Body Part 3: Body Part 4: Body Part 3: Body Part 2: Body Part 1: Body Part 4: Body Part 3: Body Part 2: Body Part 1: Body Part 4: Body Part 2: Body Part 3: Body Part 1: Body Part 4: Body Part 1: Body Part 2: Other Body Parts: Other Body Parts: Other Body Parts: Other Body Parts: An informal ratingthrough per week. , less credit for such payments per week thereafter. MM/DD/YYYY MM/DD/YYYY MM/DD/YYYY MM/DD/YYYY MM/DD/YYYY Indemnity Paid Rate Indemnity Paid Life Pension Indemnity Rate DWC-WCAB form 10214 (a) -1 Page 6 (Rev 4/2014) 4.There is Not is a need for medical treatment to cure or relieve from the effects of said\ injury (ies). 2. The injury (ies) caused temporary disability for the period for which indemnity has been paid at $ 2(a).The injury(ies) caused additional temporary disability for the \ period through in the amount of $ at the rate of $ 3. The injury(ies) caused permanent disability of % for which indemnity is payable at $ per week beginning in the sum of $ previously made. And a life pension of $ has / has not (Select one) been previously issued in case no(s) 5. Medical-legal expenses and/or liens are payable by defendant as follo\ ws: 6. Applicant's attorney requests a fee of $ Fees to be commuted as follows: 7. Liens Against compensation are payable as follows: . 8.Any accrued claims for Labor Code section 5814 penalties are included \ in this settlement unless expressly excluded.Dated Applicant Applicant's Attorney or Authorized Representative: Dated Applicant Attorney Signature DWC-WCAB form 10214 (a) -1 Page 7 (Rev 4/2014) MM/DD/YYYY MM/DD/YYYY Zip Code City Law Firm name Firm Number Last Name First Name 9.Other stipulations: State Address/PO Box (Please leave blank spaces between numbers, names or wor\ ds) Law Firm/Attorney Non Attorney Representative Defendant's Attorney or Authorized Representative: Dated DWC-WCAB form 10214 (a) -1Page 8 (Rev 4/2014) Defendant's Attorney or Authorized Representative: Defense Attorney Signature Dated MM/DD/YYYY MM/DD/YYYY Zip Code State City Law Firm Name Firm Number Last Name First Name Law Firm/Attorney Non Attorney Representative Zip Code State Law Firm Name Firm Number Last Name First Name Defense Attorney Signature Address/PO Box (Please leave blank spaces between numbers, names or wor\ ds) Address/PO Box (Please leave blank spaces between numbers, names or wor\ ds) Law Firm/Attorney Non Attorney Representative City Interpreter License Number: Interpreter Name Defendant's Attorney or Authorized Representative: Defense Attorney Signature Dated DWC-WCAB form 10214 (a) -1 Page 9 (Rev 4/2014) MM/DD/YYYY Interpreter License Number Zip Code State City Law Firm Name Firm Number Last Name First Name Law Firm/Attorney Non Attorney Representative Address/PO Box (Please leave blank spaces between numbers, names or wor\ ds)