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Information & Assistance Unit guide 12How to file a petition for reconsiderationFile a petition for reconsideration to appeal a decision by a workers' compensationjudge.The local district office of the Workers' Compensation Appeals Board (WCAB) thatissued the decision must get your petition within 20 days from the date thedecision was issued. If the judge’s decision was mailed to your residence inCalifornia, the local district office must receive your petition within 25 days.You’ll find the date the decision was issued near the judge's signature.The attached petition lists the five reasons for appealing a judge's decision. Strikeout items that do not apply to your case. Be sure to cover every item in thedecision you disagree with and include a full explanation. You may attach moresheets of paper if needed.Complete both pages of the petition. Follow the attached sample. Be sure to signand date the form. Please note there are three signature lines.Send the original of your petition to the local WCAB office that issued the decisionand copies to all the parties.Submit the following documents with your form filing in the order shown: Document Cover SheetDocument Separator Sheet (for Petition for Reconsideration)Petition for ReconsiderationDocument Separator Sheet (for Proof of Service By Mail)Proof of Service By MailKeep copies of your filings for your records.All documents filed with the WCAB must include a document cover sheet anddocument separator sheet. Please see I&A guides 17 and 18 to learn how tocomplete these forms. In addition all forms must be typed or handwritten inblock letters to insure legibility. Additional form instructions can be found on theEAMS OCR handbook athttp://www.dir.ca.gov/dwc/eams/SampleFiles/EAMS OCR%20handbook.pdf.I&A 12Rev. 06/18

Information & Assistance Unit guide 12If you need help, call an Information and Assistance (I&A) office, or attend aworkshop for injured workers. The local I&A phone numbers are attached to thisguide. You can get information on a local workshop from the I&A office or on theWeb at www.dwc.ca.gov.If you do not have the name and address of your insurance company tocomplete a form, please link to mins.asp.The information contained in this guide is general in nature and is not intended as a substitute forlegal advice. Changes in the law or the specific facts of your case may result in legalinterpretations different than those present here.When sending documents to a district office, please make sure they are not folded or stapled.Send them in a large manila envelope. Please see the EAMS OCR forms handbook for furtherinstructions.I&A 12Rev. 06/18

WORKERS’ COMPENSATION APPEALS BOARD DISTRICT OFFICESANAHEIM, 92806-21311065 North Link, Suite 170Information & Assistance Unit (714) 414-1801SACRAMENTO, 95834-2962160 Promenade Circle, Suite 300Information & Assistance Unit (916) 928-3158BAKERSFIELD, 93301-1929th1800 30 Street, Suite 100Information & Assistance Unit (661) 395-2514SALINAS, 93906-22041880 N Main Street, Suites 100 & 200Information & Assistance (831) 443-3058EUREKA, 95501-0529 * Virtual office *Information & Assistance Unit(707) 441-5723SAN BERNARDINO, 92401-1411464 W Fourth Street, Suite 239Information & Assistance Unit (909) 383-4522FRESNO, 93721-22192550 Mariposa Street, Suite 4078Information & Assistance Unit (559) 445-5355SAN DIEGO, 92108-44247575 Metropolitan Drive, Suite 202Information & Assistance Unit (619) 767-2082LONG BEACH, 90810-18701500 Hughes Way, Suite C203Information & Assistance Unit (424) 450-2565SAN FRANCISCO, 94102-7014nd455 Golden Gate Avenue, 2 FloorInformation & Assistance Unit (415) 703-5020LOS ANGELES, 90013-1105thth320 W 4 Street, 9 FloorInformation & Assistance Unit (213) 576-7389SAN JOSE, 95113-1402100 Paseo de San Antonio, Suite 241Information & Assistance Unit (408) 277-1292MARINA DEL REY, 90292-6902ndrd4720 Lincoln Boulevard, 2 and 3 FloorsInformation & Assistance Unit (310) 482-3820SAN LUIS OBISPO, 93401-87364740 Allene Way, Suite 100Information & Assistance Unit (805) 596-4159OAKLAND, 94612-1499th1515 Clay Street, 6 FloorInformation & Assistance Unit (510) 622-2861SANTA ANA, 92707-77042 MacArthur Place, Suite 600Information & Assistance Unit (714) 942-7576OXNARD, 93030-79121901 N Rice Avenue, Suite 100Information & Assistance Unit (805) 485-3528SANTA BARBARA, 93101-7538 * Satellite office *130 E Ortega StreetInformation & Assistance Unit (805) 568-1390POMONA, 91768-1653732 Corporate Center DriveInformation & Assistance Unit (909) 623-8568SANTA ROSA, 95404-477150 “D” Street, Suite 420Information & Assistance Unit (707) 576-2452REDDING, 96002-0940nd250 Hemsted Drive, 2 Floor, Suite BInformation & Assistance Unit (530) 225-2047STOCKTON, 95202-231431 E Channel Street, Suite 344Information & Assistance Unit (209) 948-7980RIVERSIDE, 92501-33373737 Main Street, Suite 300Information & Assistance Unit (951) 782-4347VAN NUYS, 91401-33706150 Van Nuys Boulevard, Suite 105Information & Assistance Unit (818) 901-5374Rev. 07/21

STATE OF CALIFORNIADWC DISTRICT OFFICE SAMPLE DOCUMENT COVERSHEETIs this a new case?YesDMore than 15 Companion CasesDNoCompanion Cases ExistDWalkthroughDTODAY'S DATESSN:Date:(MM/DD/YYYY)EAMS CASE NUMBERCase Number 1DSpecific InjuryDDATE OF INJURYCumulative Injury(Start Date: MM/DD/YYYY)IF NEW CASELEAVE BLANKDNoDYOUR SOCIALSECURITY NUMBER(End Date: MM/DD/YYYY)(If Specific Injury, use the start date as the specific date of injury)Body Part 1:USE CODE FROMBODY PART CODE LIST -Body Part 3:SEE PAGE 8Body Part 2:Body Part 4:Other Body Parts:Yes WHEN MORE THAN 5 BODY PARTS USE BODYPART NUMBER 700 IN THIS FIELDPlease check unit to be filed on ( check only one box )DADJDDEUDSIFDUEFDDINTSAU0RSUCompanion CasesCase Number 2DSpecific InjuryDCumulative Injury(Start Date: MM/DD/YYYY)(End Date: MM/DD/YYYY)(If Specific Injury, use the start date as the specific date of injury)Body Part 1:Body Part 3:Body Part 2:Body Part 4:Other Body Parts:IDWC-CA foITTl 10232.1 Rev. 5/2020 - Page 1 of 8

District office codes for place of venueLegend ta AnaBakersfieldEureka*FresnoLos AngelesLong BeachMarina del linasSanta Barbara**San BernardinoSan DiegoSan FranciscoSan JoseSan Luis ObispoSanta RosaStocktonVan Nuys* Eureka is a satellite office of Santa Rosa district office.** Santa Barbara is a satellite office of Oxnard district office.Use this document to complete forms,but do not file this document with your forms.DWC‐CA form 10232.1 Rev. 5/2020 – Page 7 of 8

BODY PART CODES 0410411420430440450498DescriptionHead - not specifiedBrainEar - not specifiedEar - externalEar - internal including hearingEye - including optic nerves and visionFace - not specifiedJaw - including chin and mandibleMouth - including lips, tongue, throat and tasteTeethNose - including nasal passages, sinus and smellFace - multiple parts any combination of above partsFace - forehead, cheeks, eyelidsScalpSkullHead - multiple injury any combination of above partsNeckUpper extremities - not specifiedArm - above wrist not specifiedArm - upper arm humerusArm - elbow head of radiusArm - forearm radius and ulnaArm - multiple parts any combination of above partsArm - not specifiedWristHand - not wrist or fingersFingersUpper extremities - multiple parts any combination ofabove partsTrunk - not specifiedAbdomen - including internal organs and groinHerniaBack - including back muscles, spine and spinal cordChest - including ribs, breast bone and internal organs ofthe chestHips - including pelvis, pelvic organs, tailbone, coccyx andbuttocksShoulders - scapula and clavicleTrunk - use for side; multiple parts any combination ofabove parts

onLower extremities - not specifiedLegs - above ankles, not specifiedThigh femurKnee PatellaLower leg tibia and fibulaLeg - multiple parts any combination of above partsLeg - not specifiedAnkle malleolusFoot not ankle or toeToesLower extremities - multiple parts any combination of abovepartsMultiple parts more than five major parts use only in fifthposition of listing of body partsBody system - not specificCirculatory system - heart - other than heart attack, blood,arteries, veins, etc.Circulatory system - Heart attackDigestive system - stomachExcretory system - kidneys, bladder, intestines, etc.Musculo-skeletal system - bones, joints, tendons, muscles,etc.Nervous system - not specifiedNervous system - StressNervous system - Psychiatric/psychRespiratory system - lungs, trachea, etc.Skin dermatitis, etc.Reproductive systemsOther body systemsCOVID-19Unclassified - insufficient information to identify body parts

SAMPLEDOCUMENT SEPARATOR SHEETProduct Delivery UnitADJDocument TypeLEGAL DOCSDocument TitlePETITION FOR RECONSIDERATIONDocument DateAuthorDATE YOU FILLED OUT THE FORMMM/DD/YYYYYOUR NAMEOffice Use OnlyReceived DateDWC-CA form 10232.2 Rev. 11/2017 Page 1MM/DD/YYYY

SAMPLESTATE OF CALIFORNIADepartment of Industrial RelationsDivision of Workers' CompensationWORKERS' COMPENSATION APPEALS BOARDYOUR NAMEvs.YOUR EMPLOYER ANDINSURANCE COMPANY)))Applicant, ))))))Defendants )Case No.EAMS/WCABPetition forReconsiderationDATE THE JUDGE'S DECISION WAS ISSUEDA decision was filed in the above-entitled case on .YOUR NAMETheis aggrieved by saiddecision and hereby petitions for reconsideration upon the following grounds: (strike out items notapplicable)1. By the order, decision or award, the Board acted without or in excess of its powers.2. The order, decision, or award was procured by fraud.3. The evidence does not justify the findings of fact.4. Petitioner has discovered new evidence material to him which he could not with reasonable diligencehave discovered and produced at the hearing.5. The findings of fact do not support the order, decision or award.In support of the above, petitioner gives the following details, including a statement of facts upon whichpetitioner relies and a discussion of the law applicable thereto:COMPLETELY DESCRIBE YOUR DISAGREEMENT WITH THE JUDGE'S DECISION.BE SURE TO INCLUDE YOUR REASON(S) WHY THE DECISION SHOULD BE CHANGED.DWC/WCAB Form 45 (Page 1) (Rev - )

WHEREFORE, Petitioner requests that reconsideration be granted; that further proceedings behad; and that decision be made to give petitioner all the benefits to which he is entitled under theLabor Code of the State of California, including the relief requested herein.YOUR SIGNATUREPetitionerAttorney for PetitionerSTATE OF CALIFORNIAYOUR COUNTYCounty of)))vs.YOUR NAMEI, the undersigned, say that I amin the above-entitled action. I have read the foregoing petition for reconsideration and know thecontents thereof, and that the same is true of my own knowledge, except as to the matters whichare therein stated upon my information or belief, and as to those matters that I believe it to betrue.I declare under penalty of perjury that the foregoing is true and correct.DATEYOUR CITYExecuted on , 20 at California.YOUR SIGNATUREPetitionerNOTE: If verification is by attorney or officer of a corporation it must comply with Section 446Code of Civil Procedure.)LIST NAME AND ADDRESS OF ALLCopy mailed to:PARTIES INVOLVED IN YOUR CASE.Date of Mailing:DATE MAILEDYOUR SIGNATUREBy:(Signature)DWC/WCAB FORM 45 (Page 2) (REV. 4-14)

SAMPLEDOCUMENT SEPARATOR SHEETProduct Delivery UnitADJDocument TypeLEGAL DOCSDocument TitlePROOF OF SERVICEDocument DateAuthorDATE YOU FILLED OUT THE FORMMM/DD/YYYYYOUR NAMEOffice Use OnlyReceived DateDWC-CA form 10232.2 Rev. 11/2017 Page 1MM/DD/YYYY