Fill and Sign the Workers Compensation Appeals Board Getrecords Form

STATE OF CALIFORNIA DIVISION O F WORKERS’ COMPENSATION WORKERS’ COMPENSATION APPEALS BOARD PRE-TRIAL CONFERENCE STATEMENT WCAB FORM 24 (REV. 2013) PAGE 1 OF ___ APPLICANT V . DEFENDANT ( S ). CASE NO . ADJ PRE - TRIAL CONFERENCE STA TEMENT §5502 (d) (3)  NOTICE OF HEARING LOCATION : DATE : TIME: SETTLEMENT CONFERENCE JUDGE : APPEARANCES  INJURED WORKER :  INJURED WORKER ’S ATTORNEY :  ATTY  HRG REP (FIRM NAME AND PERSON APPEARING )  DEFENDANT ’S ATTORNEY :  ATTY  HRG REP  ATTY  HRG REP  ATTY  HRG REP  ATTY  HRG REP (FIRM NAME AND PERSON APPEARING ) (DEFENDANT )  OTHERS APPEARING : ( L.C ., INTERPRETERS , ETC .)  ADDRESS RECORD CHANG ES: BOX BELOW TO BE COMPLETED ONLY BY WORKERS’ COMPENSATION JUDGE DISPOSITION : SET FOR REGULAR HEAR ING:  WCAB NOTICE  NOTICE WAIVED  1 HOUR  2 HOURS  ½ DAY  ALL DAY  LIEN TRIAL  BEFORE ANY WCJ  BEFORE WCJ  BEFORE ANY WCJ OTHER THAN  CASE (S ) SET ON AT WCJ IN (DATE) (TIME) (LOCATION )  OTHER DISPOSITION AN D ORDERS: SERVICE AS ORDERED ON PAGE 4 WORKERS ’ COMPENSATION JUDGE STATE OF CALIFORNIA DIVISION O F WORKERS’ COMPENSATION WORKERS’ COMPENSATION APPEALS BOARD PRE-TRIAL CONFERENCE STATEMENT CASE NO. ______________________ WCAB FORM 24 (REV. 2013) PAGE 2 OF ___ STIPULATIONS THE FOLLOWING FACTS ARE ADMITTED : 1. , BORN ______________ WHILE  EMPLOYED  ALLEGEDLY EMPLOYED  ON  DURING THE PERIOD( S) AS A (N ) , OCCUPATIONAL GROUP NUMBER AT , CALIFORNIA , BY  SUSTAINED INJURY ARISING OUT OF AND IN THE COURSE OF EMPLOYMENT TO  CLAIMS TO HAVE SUSTAINED INJURY ARISING OUT OF AND IN THE COURSE OF EMPLOYMENT TO 2. AT THE TIME OF INJURY THE EMPLOYER ’S WORKERS ’ COMPENSATION CARRIER WAS  THE EMPLOYER WAS  PERMISSIBLY SELF -INSURED  UNINSURED  LEGALLY UNINSURED 3. AT THE TIME OF INJURY , THE EMPLOYEE ’S EARNINGS WERE $PER WEEK, WARRANTING INDEMNITY RATES OF $ FOR TEMPORARY DISABILITY AND $ FOR PERMANENT DISABILITY . 4. THE CARRIER /EMPLOYER HAS PAID COMPENSATION AS FOLLOWS : (TD/PD /VRMA ) TYPE WEEKLY RATE PERIOD TYPE WEEKLY RATE PERIOD  THE EMPLOYEE HAS BEEN ADEQUATELY COMPENSATED FOR ALL PERIODS OF T /D CLAIMED THROUGH 5. THE EMPLOYER HAS FURNISHED  ALL  SOME  NO MEDICAL TREATMENT . THE PRIMARY TREATING PHYSICIAN IS 6.  NO ATTORNEY FEES HAVE BEEN PAID AND NO ATTORNEY FEE ARRANGEMENTS HAVE BEEN MADE .7.  OTHER STIPULATIONS APPLICANT DEFENDANT LIEN CLAIMANT/OTHER STATE OF CALIFORNIA DIVISION O F WORKERS’ COMPENSATION WORKERS’ COMPENSATION APPEALS BOARD PRE-TRIAL CONFERENCE STATEMENT CASE NO. ______________________ WCAB FORM 24 (REV. 2013) PAGE 3 OF ___ 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 STATE OF CALIFORNIA DIVISION O F WORKERS’ COMPENSATION WORKERS’ COMPENSATION APPEALS BOARD PRE-TRIAL CONFERENCE STATEMENT CASE NO. ______________________ WCAB FORM 24 (REV. 2013) PAGE 4 OF ___ THIS PAGE FOR JUDGE ’S USE ONLY JUDGE ’ S CONFERENCE NOTES : ORDERS  IT IS ORDERED PURSUANT TO WCAB RUL E 10500, THAT  DEFENDANT  APPLICANT  LIEN CLAIMANT SERVE FORTHWITH THIS  PRE - TRIAL CONFERENCE STA TEMENT  NOTICE OF HEARING O N ALL PARTIES OR THE IR REPRESENTATIVE SHOWN ON THE OFFICIA L ADDRESS RECORD AND ANY ADDITIONAL LIEN CLAIMANTS WHOSE LIEN S ARE SHOWN UNDER ISSUES ( PAGE 3).  IT IS FURTHER ORDERE D THAT  DEFENDANT  APPLICANT  LIEN CLAIMANT SE RVE TIMELY NOTICE OF THE TIME AND PLACE OF ALL REG ULAR HEARING SESSION S ON ALL LIEN CLAIMA NTS WHOSE LIENS ARE SHOWN UNDER ISSUES , TOGETHER WITH THE FOLLOWING NOTICE : YOUR LIEN IS AT ISSU E AND WILL BE ADJUDI CATED AT REGULAR HEA RING . IT IS FURTHER ORDERE D THAT THE PROOF OF SE RVICE ORDERED ABOVE BE FILED WITH THE WC AB ONLY ON REQUEST OF THE ASSIGNED WORKERS ’ COMPENSATION JUDGE . OTHER DISPOSITION AN D ORDERS : SERVICE OF THIS DOCU MENT WAS MADE PERSON ALLY UPON BY WCJ . DATE ______________ WORKERS ’ COMPENSATION JUDGE STATE OF CALIFORNIA DIVISION O F WORKERS’ COMPENSATION WORKERS’ COMPENSATION APPEALS BOARD PRE-TRIAL CONFERENCE STATEMENT CASE NO. ______________________ WCAB FORM 24 (REV. 2013) EXHIBITS  APPLICANT  DEFENDANT  LIEN CLAIMANT DESCRIPTION DATE  APPEALS BOARD W ITNESSES ABOVE LISTINGS OF EXHIBITS AND WITNESSES REVIEWED BY ALL PARTIES . APPLICANT DEFENDANT LIEN CLAIMANT/OTHER PAGE ____ OF ___