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Information & Assistance Unit guide 18How to complete a document separator sheetIn addition to the document cover sheet (see guide 17), forms filed with your localWorkers’ Compensation Appeals Board (WCAB) district office need a “documentseparator sheet.” We need the separator sheet so information in the form thatfollows it can be read by our Electronic Adjudication Management System (EAMS).The separator sheet is required even if you are only filing one document. Thismeans you will be submitting at least three documents, in the following order, withanything you file at the WCAB:1. A document cover sheet2. A document separator sheet3. The form you need to fileIf you are filing supporting documents with your form you will need separatorsheets to identify them.You may complete the attached separator sheet using a typewriter or with blockprinting. This form can also be completed online orm10232 2.pdf.Use the attached sample form as a guide.Keep in mind the separator sheet provides information about the document thatfollows it. To fill out the separator sheet: Select the correct “product delivery unit” (the unit that will receive your formor document). You must select ADJ, DEU, RSU, VOC, or INT. Please see theappendix and sample form for more informationSelect the “document type” for the product delivery unit chosen. See theappendix for the document types available under each product delivery unit.For example, under ADJ, the only four document types are: legal document,liens and bills, medical document and miscellaneous. Use ONLY the optionsprovided. Do not write in a document type that doesn’t exist for the unit. Ifyou are filling out the separator sheet on the Web site, the available optionsare in a drop down menu on the formSelect the “document title” from the appendix. Again, use ONLY the optionsprovided. Do not write in a document title that doesn’t exist for the unit anddocument type you selected. If you are filling the separator sheet out on theWeb site, the available options are in a drop down menu on the formI&A 18Rev. 06/18
Information & Assistance Unit guide 18 Fill in the “document date” (such as the date of medical report or date of aletter) using two-digit months and dates, and four digit years. The month,date, and year should be separated by a slash, like this: 02/15/2008Put the name of the person or organization who wrote the document in the“author” box. For example, if the document following the separator sheet isa form you filled out, you are the author. If the document following theseparator sheet is a doctor’s report, the doctor is the author. If your claimsadministrator is the author you need to know the “uniform assigned name”of that company and put that in the box. You can find the uniform assignedname of your claims administrator on the Web site sAdmins.asp.Send the completed filing packet to the correct local WCAB district office. WCABdistrict office addresses and phone numbers are attached to this guide.Additional instructions for filing forms in EAMS can be found on line in the “EAMSOCR forms handbook” athttp://www.dir.ca.gov/dwc/eams/SampleFiles/EAMS OCR%20handbook.pdf.If 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.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 18Rev. 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
SAMPLEDOCUMENT SEPARATOR SHEETProduct Delivery UnitDocument TypeDocument TitleSELECT UNITSELECT DOCUMENT TYPE, REFER TO LISTSELECT DOCUMENT TITLE, REFER TO LISTDocument DateAuthorDATE YOU FILLED OUT THE FORMMM/DD/YYYYYOUR NAMEOffice Use OnlyReceived DateDWC-CA form 10232.2 Rev. 11/2017 Page 1MM/DD/YYYY
PRODUCT DELIVERY ADJADJADJADJRev. 11/2017DOCUMENT TYPEIBRIMRLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSDOCUMENT TITLEAPPEAL OF DETERMINATION OF AD‐IBRAPPEAL OF DETERMINATION OF AD‐IMR10770.5 VERIFICATION10770.6 VERIFICATION132A1990 ‐ 1993 WINDOW PERIOD APPLICATION1990 ‐ 1993 WINDOW PERIOD APPLICATION ‐ DEATH CLAIM4906(g) DECLARATION4906(h) DECLARATIONAMENDED APPLICATION FOR ADJUDICATIONAMENDED APPLICATION FOR ADJUDICATION‐DEATHAMENDED COMPROMISE AND RELEASEAMENDED STIPULATIONSANSWERANSWER TO 132AANSWER TO APPLICATION FOR ADJUDICATION OF CLAIMANSWER TO PETITION FOR RECONSIDERATIONANSWER TO PETITION FOR REMOVALANSWER TO S & WAPPEAL OF DETERMINATION OF A.D.‐OTHERAPPEAL OF DETERMINATION OF A.D.‐RSUAPPEAL OF DIRECTOR'S RETURN TO WORK SUPPLEMENT DECISIONAPPLICATION FOR ADJUDICATIONAPPLICATION FOR ADJUDICATION OF CLAIM‐DEATHAPPLICATION FOR SUBSEQUENT INJURIES FUND BENEFITSARBITRATION SUBMITTAL FORMBENEFIT NOTICEBENEFIT PRINTOUTBIRTH CERTIFICATEC&R: RESPONSE TO LETTER REQUESTING INFORMATIONCHANGE OF ADDRESSCHANGE OF HANDLING LOCATIONCOMPROMISE AND RELEASECOMPROMISE AND RELEASE DEPENDENCY CLAIMCOMPROMISE AND RELEASE‐SIGNEDCONFIRMATION OF LIEN ACTIVATION FEE
PRODUCT DELIVERY ADJADJADJADJRev. 11/2017DOCUMENT TYPELEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSDOCUMENT TITLECONFIRMATION OF PAYMENT 2004‐2006DEATH CERTIFICATEDECLARATION OF READINESS TO PROCEEDDECLARATION OF READINESS TO PROCEED TO EXPEDITED HEARINGDEPOSITION TRANSCRIPTDISMISSAL OF ATTORNEYDWC‐1 CLAIM FORMFEE DISCLOSURE STATEMENTMARRIAGE LICENSEMINUTES OF HEARINGNOTICE OF CHANGE OF ADMINISTRATORNOTICE OF CHANGE OF REPRESENTATIONNOTICE OF NON‐REPRESENTATIONNOTICE OF OFFER OF REGULAR WORKNOTICE OF PERMANENT DISABILITY BENEFITSNOTICE OF POTENTIAL SJDBNOTICE OF REPRESENTATIONNOTICE OF TEMPORARY DISABILITY BENEFITS (DWC 500‐B)NOTICE REGARDING MPNOBJECTION ‐ OTHEROBJECTION TO DECLARATION OF READINESS TO PROCEEDOBJECTION TO PETITION TO TERMINATE LIABILITY FOR TEMPORARY DISABILITYOBJECTION TO PETITION/REQUEST FOR DISMISSALOBJECTION TO VENUEPETITION ‐ OTHERPETITION BY NON‐PHYSICIAN LIEN CLAIMANT FOR MEDICAL INFORMATIONPETITION FOR APPOINTMENT OF GUARDIAN AD LITEMPETITION FOR APPOINTMENT OF REPLACEMENT QMEPETITION FOR APPOINTMENT OF REPLACEMENT QME PANELPETITION FOR ATTORNEY FEESPETITION FOR AUTOMATIC REASSIGNMENTPETITION FOR CERTIFICATIONPETITION FOR CHANGE OF GUARDIAN AD LITEMPETITION FOR CHANGE OF VENUEPETITION FOR COMMUTATIONPETITION FOR CONSOLIDATION
PRODUCT DELIVERY ADJADJADJADJRev. 11/2017DOCUMENT TYPELEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSDOCUMENT TITLEPETITION FOR CONTRIBUTIONPETITION FOR COSTSPETITION FOR CREDIT FOR OVERPAYMENT OF BENEFITSPETITION FOR DEPOSITION ATTORNEY FEE (LC 5710)PETITION FOR DEPOSITION ATTORNEY FEE (LC 5710) ‐ WALKTHROUGHPETITION FOR DISCOVERY ORDERPETITION FOR DISMISSALPETITION FOR DISMISSAL OF A PARTYPETITION FOR DISQUALIFICATIONPETITION FOR FINDING OF FACTPETITION FOR INCREASED BENEFITS FOR SERIOUS AND WILLFUL MISCONDUCTPETITION FOR JOINDERPETITION FOR ORDER ASSIGNING SECOND PANEL QMEPETITION FOR ORDER COMPELLING SERVICE OF MEDICAL RECORDPETITION FOR ORDER CORRECTING CLERICAL ERRORPETITION FOR ORDER OF CONFIDENTIALITYPETITION FOR ORDER OF PUBLICATIONPETITION FOR PENALTIESPETITION FOR RECONSIDERATIONPETITION FOR RECONSIDERATION/REMOVALPETITION FOR REHAB ATTORNEY FEEPETITION FOR REHAB ATTORNEY FEE ‐ WALKTHROUGHPETITION FOR REMOVALPETITION FOR RESTITUTIONPETITION FOR SANCTIONS/COSTPETITION FOR STAY OF PROCEEDINGSPETITION FOR THIRD PARTY CREDITPETITION FOR WRIT OF ATTACHMENTPETITION TO BAR RECEIPT OF BENEFITSPETITION TO BE RELIEVED AS ATTORNEY OF RECORDPETITION TO CHANGE ADMINISTRATOR OF AWARDPETITION TO COMPEL ATTENDANCE AT MEDICAL EVALUATIONPETITION TO COMPEL ATTENDANCE AT MEDICAL EVALUATION ‐ WALKTHROUGHPETITION TO COMPEL DEPOSITIONPETITION TO COMPEL DEPOSITION ‐ WALKTHROUGHPETITION TO DISMISS APPLICANT
PRODUCT DELIVERY ADJADJADJADJRev. 11/2017DOCUMENT TYPELEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSDOCUMENT TITLEPETITION TO DISMISS ATTORNEYPETITION TO DISMISS PARTY DEFENDANTPETITION TO DISQUALIFY PANEL QMEPETITION TO ENFORCEPETITION TO ENFORCE IBR DETERMINATIONPETITION TO JOIN APPLICANTPETITION TO JOIN DEFENDANTPETITION TO JOIN UEBTFPETITION TO QUASH DEPOSITIONPETITION TO QUASH SUBPOENAPETITION TO REOPENPETITION TO REOPEN TO REDUCEPETITION TO RESOLVE MED‐LEGAL DISPUTE‐ NON‐IBRPETITION TO SEAL THE RECORDPETITION TO SET ASIDE COMPROMISE AND RELEASEPETITION TO SET ASIDE STIPULATIONSPETITION TO STRIKE RATING INSTRUCTIONSPETITION TO SUSPEND PROCEEDINGSPETITION TO TERMINATE LIABILITY FOR MEDICAL TREATMENTPETITION TO TERMINATE LIABILITY FOR TEMPORARY DISABILITY INDEMNITYPETITION TO TRANSFER CARE TO MEDICAL PROVIDER NETWORKPETITION TO UNSEAL THE RECORDPETITION TO VACATE SUBMISSIONPOINTS AND AUTHORITIESPOINTS AND AUTHORITIES‐TRIAL BRIEF‐HEARING BRIEFPRE‐TRIAL CONFERENCE STATEMENT (5 PAGER)PROOF OF SERVICEPROPOSED ORDER/AWARDPROPOSED STIPULATION AWARD AND/OR ORDERQME WAIVERREQUEST FOR CONTINUANCEREQUEST FOR ORDER TAKING OFF CALENDARREQUEST TO WITHDRAW PETITION FOR RECONSIDERATIONREQUEST TO WITHDRAW PETITION FOR REMOVALRESPONSE TO PETITIONRESUBMITTED 1990 APPLICATION
PRODUCT DELIVERY ADJADJADJADJRev. 11/2017DOCUMENT TYPELEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLIENS AND BILLSLIENS AND BILLSLIENS AND BILLSLIENS AND BILLSLIENS AND BILLSLIENS AND BILLSLIENS AND BILLSLIENS AND BILLSLIENS AND BILLSLIENS AND BILLSMEDICAL DOCSMEDICAL DOCSMEDICAL DOCSMEDICAL DOCSMEDICAL DOCSMISCMISCMISCMISCMISCDOCUMENT TITLERETURN TO WORK SUPPLEMENT PROGRAM ANSWER TO APPEALSPECIAL NOTICE OF LAWSUITSTIPS: RESPONSE TO LETTER REQUESTING INFORMATIONSTIPULATION AND AWARD AND/OR ORDERSTIPULATION WITH AWARD(DEATH)STIPULATIONS WITH REQUEST FOR AWARDSTIPULATIONS WITH REQUEST FOR AWARD DOI post 1‐1‐2013STIPULATIONS WITH REQUEST FOR AWARD‐SIGNEDSUBSTITUTION OF ATTORNEYSUPPLEMENTAL PETITION FOR RECONSIDERATIONTHIRD PARTY COMPROMISE AND RELEASETRANSCRIPT OF RECORDVENUE VERIFICATIONWAGE STATEMENTWITHDRAWAL OF DECLARATION OF READINESS TO PROCEEDWRIT4903.8 (A) (B) ASSIGNMENT4903.8 (D) DECLARATIONBILLS‐OTHERCONFIRMATION OF LIEN FILING FEEEDD LIENITEMIZED STATEMENTMEDICAL BILLSNOTICE AND REQUEST FOR ALLOWANCE OF LIENORIGINAL BILLREQUEST FOR WITHDRAWAL OF LIENALL MEDICAL REPORTSAME REPORTSP & S REPORTQME REPORTSTREATING PHYSICIANCONSULTATIVE RATINGCORRESPONDENCE‐OTHERSETTLEMENT OFFER LETTERSUBPOENASUBPOENA DUCES TECUM
PRODUCT DELIVERY RSURSURSURSURev. 11/2017DOCUMENT TYPEMISCMISCMISCDEU DOCS ‐ OTHERDEU DOCS ‐ OTHERDEU DOCS ‐ OTHERDEU DOCS ‐ OTHERDEU FORMSDEU FORMSDEU FORMSDEU FORMSDEU FORMSDEU FORMSDEU FORMSDEU FORMSMEDICAL REPORTSMEDICAL REPORTSMEDICAL REPORTSMEDICAL REPORTSMEDICAL REPORTSMISCMISCAD LEGALAD LEGALAD LEGALAD LEGALMEDICAL DOCSMEDICAL DOCSMISCMISCMISCMISCDWC ‐ AD FormsDWC ‐ AD FormsDWC ‐ AD FormsDWC ‐ AD FormsDOCUMENT TITLESUMMARY RATINGTRANSMITTAL LETTERTYPED OR WRITTEN LETTEREARNINGS INFORMATIONJOB DESCRIPTIONPHOTOGRAPHSRESPONSE TO REQUEST FOR FACTUAL CORRECTIONCOMMUTATION REQUESTEMPLOYEES PERMANENT DISABILITY QUESTIONAIREFACTUAL CORRECTION FORMREQUEST FOR CONSULTATIVE RATINGREQUEST FOR INFORMAL RATING BY INSURANCE CARRIER OR SELF‐INSURERREQUEST FOR RECONSIDERATION OF SUMMARY RATING BY THE ADREQUEST FOR SUMMARY RATING DETERMINATION ‐ PTPREQUEST FOR SUMMARY RATING DETERMINATION ‐ QME REPORTAMEDEFAULT QME (REPRESENTED WITH DOI ON/AFTER 1‐1‐05)PANEL QME (NON‐REPRESENTED ALL DOI)REPRESENTED QME (represented with DOI before 1‐1‐05)TREATING PHYSICIANPROOF OF SERVICETYPED OR WRITTEN LETTERMEDICAL REPORTSMISCELLANEOUSPETITION FOR CHANGE OF PRIMARY TREATING PHYSICIANRESPONSE TO PETITION FOR CHANGE OF PRIMARY TREATING PHYSICIANMEDICAL REPORTSREQUESTS TO I&A FOR REPLACEMENT OR ADDITIONAL PANEL QME PANELCORRESPONDENCEGENERAL PUBLIC REQUEST FOR INFORMATIONI & A CONFERENCE APPOINTMENT NOTICEREQUEST TO I & A FOR CONFERENCEDWC‐AD 10118 NOTICE OF OFFER OF REGULAR WORKDWC‐AD 10133.32 SUPPLEMENTAL JOB DISPLACEMENT NON‐TRANSFERABLE VOUCHERDWC‐AD 10133.33 DESCRIPTION OF EMPLOYEE'S JOB DUTIESDWC‐AD 10133.35 NOTICE OF OFFER OF REG MOD OR ALTERNATIVE WORK
PRODUCT DELIVERY SAUSAUSAUSAURev. 11/2017DOCUMENT TYPEDWC ‐ AD FormsDWC ‐ AD FormsDWC ‐ AD FormsDWC ‐ AD FormsDWC ‐ AD FormsNON‐FORM CORRESPONDENCEOTHEROTHERSUPPORTING DOCUMENTSSUPPORTING DOCUMENTSSUPPORTING DOCUMENTSSUPPORTING DOCUMENTSSUPPORTING DOCUMENTSSUPPORTING DOCUMENTSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSDOCUMENT TITLEDWC‐AD 10133.36 PHYSICIAN'S RETURN‐TO‐WORK & VOUCHER REPORTDWC‐AD 10133.53 NOTICE OF OFFER OF MODIFIED OR ALTERNATIVE WORKDWC‐AD 10133.57 SUPPLEMENTAL JOB DISPLACEMENT VOUCHERDWC‐AD‐10133.55 REQUEST FOR DISPUTE RESOLUTION BEFORE THE ADOBJECTION ‐ OTHERLETTEROTHER CORRESPONDENCEPROOF OF SERVICEERGONOMIC REPORTJOB DESCRIPTIONMEDICAL REPORTPOSITION STATEMENTSCHOOL & VRTWC INVOICESVRTWC REPORT10770.5 VERIFICATION10770.6 VERIFICATION4906(h) DECLARATIONANSWERANSWER TO PETITION FOR RECONSIDERATIONANSWER TO PETITION FOR REMOVALCONFIRMATION OF LIEN ACTIVATION FEECONFIRMATION OF PAYMENT 2004‐2006DECLARATION OF READINESS TO PROCEEDDISMISSAL OF ATTORNEYNOTICE OF CHANGE OF REPRESENTATIONNOTICE OF REPRESENTATIONOBJECTION ‐ OTHEROBJECTION TO DECLARATION OF READINESS TO PROCEEDOBJECTION TO PETITION/REQUEST FOR DISMISSALOBJECTION TO VENUEPETITION ‐ OTHERPETITION FOR AUTOMATIC REASSIGNMENTPETITION FOR CERTIFICATIONPETITION FOR CHANGE OF VENUEPETITION FOR CONSOLIDATIONPETITION FOR COSTS
PRODUCT DELIVERY SAUSAUSAUSAURev. 11/2017DOCUMENT TYPELEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSDOCUMENT TITLEPETITION FOR CREDIT FOR OVERPAYMENT OF BENEFITSPETITION FOR DISCOVERY ORDERPETITION FOR DISMISSALPETITION FOR DISMISSAL OF A PARTYPETITION FOR DISQUALIFICATIONPETITION FOR FINDING OF FACTPETITION FOR JOINDERPETITION FOR ORDER CORRECTING CLERICAL ERRORPETITION FOR ORDER OF CONFIDENTIALITYPETITION FOR ORDER OF PUBLICATIONPETITION FOR PENALTIESPETITION FOR RECONSIDERATIONPETITION FOR RECONSIDERATION/REMOVALPETITION FOR REMOVALPETITION FOR RESTITUTIONPETITION FOR SANCTIONS/COSTPETITION TO BAR RECEIPT OF BENEFITSPETITION TO BE RELIEVED AS ATTORNEY OF RECORDPETITION TO COMPEL DEPOSITIONPETITION TO COMPEL DEPOSITION ‐ WALKTHROUGHPETITION TO DISMISS APPLICANTPETITION TO DISMISS ATTORNEYPETITION TO DISMISS PARTY DEFENDANTPETITION TO ENFORCEPETITION TO JOIN DEFENDANTPETITION TO JOIN PARTY DEFENDANTPETITION TO QUASH DEPOSITIONPETITION TO QUASH SUBPOENAPETITION TO SEAL THE RECORDPETITION TO SET ASIDE COMPROMISE AND RELEASEPETITION TO SET ASIDE STIPULATIONSPETITION TO SUSPEND PROCEEDINGSPETITION TO UNSEAL THE RECORDPETITION TO VACATE SUBMISSIONPOINTS AND AUTHORITIES‐TRIAL BRIEF‐HEARING BRIEFPROOF OF SERVICE
PRODUCT DELIVERY SAURev. 11/2017DOCUMENT TYPELEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLEGAL DOCSLIENS AND BILLSLIENS AND BILLSLIENS AND BILLSLIENS AND BILLSLIENS AND BILLSLIENS AND BILLSLIENS AND BILLSLIENS AND BILLSLIENS AND BILLSLIENS AND BILLSLIENS AND BILLSMEDICAL DOCSMEDICAL DOCSMEDICAL DOCSMEDICAL DOCSMEDICAL DOCSMISCMISCMISCMISCMISCDOCUMENT TITLEPROPOSED ORDER/AWARDPROPOSED STIPULATION AWARD AND/OR ORDERREQUEST FOR CONTINUANCEREQUEST FOR ORDER TAKING OFF CALENDARREQUEST TO WITHDRAW PETITION FOR RECONSIDERATIONREQUEST TO WITHDRAW PETITION FOR REMOVALRESPONSE TO PETITIONSTIPULATION WITH AWARD(DEATH)STIPULATIONS WITH REQUEST FOR AWARDSTIPULATIONS WITH REQUEST FOR AWARD DOI post 1‐1‐2013SUBSTITUTION OF ATTORNEYWITHDRAWAL OF DECLARATION OF READINESS TO PROCEED4903.05(c) PROVIDER DECLARATION4903.8 (a) (b) ASSIGNMENT4903.8 (d) DECLARATIONBILLS‐OTHERCONFIRMATION OF LIEN FILING FEEITEMIZED STATEMENTMEDICAL BILLSNOTICE AND REQUEST FOR ALLOWANCE OF LIENORIGINAL BILLREQUEST FOR WITHDRAWAL OF LIENSUPPLEMENTAL LIEN FORM AND SECTION 4903.05(c) DECLARATIONALL MEDICAL REPORTSAME REPORTSP & S REPORTQME REPORTSTREATING PHYSICIANCORRESPONDENCE‐OTHERSUBPOENASUBPOENA DUCES TECUMTRANSMITTAL LETTERTYPED OR WRITTEN LETTER
The separator sheet is required even if you are only filing one document. This means you will be submitting at least three documents, in the following order, with anything you file at the WCAB: 1. A document cover sheet 2. A document separator sheet 3. The form you need to file If you are filing supporting documents with your form you will need .
