CALIFORNIA WORKERS' COMPENSATION PRACTICE (4th Edition) June 2014 TABLE OF CONTENTS File Name Book Section Title CH10 Chapter 10 Representing Injured Workers 10-007 10.7 Potential New Client Questionnaire 10-008 10.8 Letter Confirming Appointment 10-009 10.9 Nonengagement Letter 10-017 10.17 Supplementary Fee Disclosure Statement 10-020 10.20 Venue Authorization 10-021 10.21 Authorization for Release of Medical Information 10-022 10.22 Authorization for Release of Psychiatric, Drug, and Alcohol Treatment Records 10-023 10.23 Authorization for Release of Employment and School Records 10-024 10.24 Letter to Workers Compensation Insurance Rating Bureau Requesting Compensation Coverage Information 10-026 10.26 10.30 Injured Employee and Dependents 10.27 Employment Status 10.28 Earnings 10.29 Employer s Insurance 10.30 Injury 10-031 10.31 10.34 Injuries Resulting in Death 10.32 Prior Injuries or Disabilities 10.33 Medical Treatment and Expenses 10.34 Compensation to Date 10-035 10.35 Notice of Supplemental Job Displacement Benefit (Voucher) (Injuries Occurring On or After 1/1/2004 and Before 1/1/2013) 10-035A 10.35A Notice of Supplemental Job Displacement Benefit (Voucher) (Injuries Occurring On or After January 1, 2013) 10-036 10.36 Claim Form; Procedural Information 10-038 10.38 Letter of Representation to New Client 10-041 10.41 Notice of Representation to Employer 10-043 10.43 Letter to Insurer or Adjusting Agency 10-047 10.47 Letter Designating Primary Treating Physician 10-048 10.48 Letter Regarding Medical Bills Received by Applicant 10-056 10.56 Letter to Worker Regarding Deposition 10-057 10.57 Letter Requesting Payment for Fees and Costs Associated With Injured Worker s Deposition
10-058 10.58 Petition for Attorney Fees and Expenses for Injured Worker s Deposition 10-059 10.59 Letter Requesting Worker to Review Deposition Transcript 10-061 10.61 Letter to Worker Regarding Medical Evaluation 10-063 10.63 Letter to Doctor to File Lien 10-064 10.64 Letter Notifying Worker of Hearing Request 10-065 10.65 Letter Notifying Worker of Settlement Conference Date 10-070 10.70 Letter Notifying Worker of Closed Case File CH11 Chapter 11 Representing Defendants 11-022 11.22 Statement of Employee s Gross Earnings 11-029 11.29 Compensation Litigation Transmittal Note 11-034 11.34 Letter to Employment Development Department 11-037 11.37 Letter Requesting Signed Social Security Earnings Release 11-042 11.42 Applicant s Deposition Worksheet 11-043 11.43 Petition to Compel Answers to Questions and Production of Documents at Deposition 11-046 11.46 Petition for Order Compelling Production of Psychiatric Records; Order 11-048 11.48 Deposition Letter to Primary Treating Physician 11-049 11.49 Petition to Compel Attendance at Medical Evaluation 11-055 11.55 Petition for Joinder 11-057 11.57 Letter to Employer Re: Lack of Coverage 11-058 11.58 Letter to Applicant or Codefendant Re: Lack of Coverage 11-059 11.59 Petition to Dismiss for Lack of Coverage; Order 11-061 11.61 Petition to Strike Application (Lab C 4906(g), Declaration Missing); Order 11-062 11.62 Petition to Dismiss No Employment Within Last Year of Injurious Exposure 11-063 11.63 Petition to Dismiss No Coverage Within Last Year of Injurious Exposure 11-064 11.64 Petition to Dismiss Statute of Limitations 11-065 11.65 Petition to Dismiss Failure to Prosecute 11-081 11.81 Objection to Medical-Legal Expense 11-085 11.85 Objection to Medical Treatment Expense 11-088 11.88 Petition for Credit for Third Party Recovery 11-089 11.89 Petition for Restitution From Injured Worker 11-090 11.90 Petition for Reimbursement From Codefendant 11-092 11.92 Petition for Reimbursement of Paid Medical-Legal Expense
11-095 11.95 Letter From Insurer s Attorney Advising Employer of Serious and Willful Misconduct Petition 11-097 11.97 Letter Advising Insured Employer of Petition Alleging Discrimination CH12 Chapter 12 Time Limitations 12-010 12.10 Notice of Injury 12-051 12.51 Allegations of Incompetence, Competence Regained CH13 Chapter 13 Filing With the Workers Compensation Appeals Board 13-021 13.21 Parties Checklist 13-085 13.85 Sample Allegations of Injury and Exposure 13-095 13.95 Petition for Award for Employer s Serious and Willful Misconduct 13-095A 13.95A Petition for Award for Employer s Serious and Willful Misconduct Violation of Safety Order (Lab C 4553.1) 13-101 13.101 Cite or Refer Correctly to Safety Order or Statute 13-102 13.102 State How Safety Order or Statute Was Violated 13-103 13.103 Sample Allegation: General Misconduct 13-105 13.105 Petition for Award Under Lab C 132a 13-113 13.113 Declaration Under Lab C 4906(g) 13-150 13.150 Answer to Petition and Request for Dismissal or Continuance 13-155 13.155 Initial Appearance CH14 Chapter 14 Gathering Evidence 14-011 14.11 Authorization for Medical Information 14-034 14.34 Declaration by Signing Physician 14-079 14.79 Checklist: Deposition Information From Employee 14-100 14.100 Sample Order Re: Confidentiality CH16 Chapter 16 Settlement 16-034 16.34 Addendum to Compromise and Release 16-043 16.43 Sample Computation of Fair Allocation to Unemployment Compensation Disability Lien Claim (Baird Formula) 16-044 16.44 Sample Computation of Lien Reduction Under Lab C 4903.1(a)(4) 16-077 16.77 Preparation 16-084 16.84 Sample Letter Requesting Fee (To Accompany WCAB Form 4) CH17 Chapter 17 Preparing for Trial 17-040 17.40 Petition for Automatic Reassignment to Another Workers Compensation Judge 17-042 17.42 Petition to Disqualify Assigned Workers Compensation Judge 17-047 17.47 Checklist: Refining Issues
17-079 17.79 Additions to Employer s Report of Occupational Injury or Illness 17-099 17.99 Letter to Applicant s Attorney Requesting Earnings Information 17-107 17.107 Petition to Dismiss Application 17-108 17.108 Petition to Dismiss for Lack of Prosecution (Injuries Occurring Before January 1, 1990, or On or After January 1, 1994) 17-110 17.110 Petition to Dismiss Improperly Joined Insurer 17-111 17.111 Petition to Join Additional Employers and Insurers 17-112 17.112 Petition for Order Directing Exhumation and Autopsy 17-113 17.113 Petition to Suspend Proceedings and to Compel Medical Examination 17-114 17.114 Petition to Bar Applicant s Right to Disability Payments CH21 Chapter 21 Reconsideration 21-028 21.28 21.35 Caption; Introduction 21.29 Preliminary Statement; Grounds 21.30 Statement of Contentions 21.31 Summary of Material Facts 21.32 Argument 21.33 Request for Transcript 21.34 Prayer 21.35 Signature; Verification 21-040 21.40 Statement on Petition 21-041 21.41 Statement in Letter of Transmittal 21-042 21.42 Declaration of Service CH22 Chapter 22 Judicial Review 22-024 22.24 22.26 Cover 22.25 Topical Index 22.26 Table of Authorities Cited 22-028 22.28 22.42 Formal Address 22.29 Opening Paragraph 22.30 When Petitioner Is Employee 22.31 When Petitioner Is Dependent 22.32 When Petitioners Are Defendants 22.33 Proceedings Before Board 22.34 Grounds for Review Raised in Reconsideration Petition 22.35 Questions Presented 22.36 Incorporation of Points and Authorities 22.37 Petition Timely and Proper 22.38 No Right to Appeal 22.39 Residence and Beneficial Interest
22.40 Prayer; Signature 22.41 By Affidavit 22.42 By Declaration 22-047 22.47 Statement of Material Facts 22-056 22.56 Stipulation Extending Time to File Answer 22-057 22.57 Application for Extension of Time to Answer 22-058 22.58 Order Extending Time to File Answer 22-060 22.60 Title When Attorney Fee Requested Under Lab C 5801 22-061 22.61 Opening Paragraph 22-062 22.62 Identification of Respondent; Denial of Allegations in Petition 22-063 22.63 Allegation of Lack of Reasonable Basis for Petition 22-064 22.64 Questions Presented 22-065 22.65 Statement of Material Facts 22-067 22.67 Conclusion 22-074 22.74 Conclusion 22-089 22.89 Opening Paragraph 22-091 22.91 Prayer 22-097 22.97 Caption, Formal Address, and Opening Paragraph 22-098 22.98 Exhibits CH23 Chapter 23 Supplemental Proceedings 23-059 23.59 Petition for Contribution Under Lab C 5500.5