“ (2) When did this offer begin? (You must answer “YES” to select this item.) The offer has been made within the past two weeks. (3) Is this offer dependent upon the Employee's having been injured at your place of employment? (Yes, if you are willing to work at another location.) (4) I have been injured within the last thirty days (Please select the date) at my place of employment. (5) In connection with this offer, my Employer seeks an additional 1,500 to cover: (Please select the condition and amount) Medical payment for an injury that resulted in me (or my employee) receiving a medical diagnosis that I have been ordered to attend and treatment. Payment for a medical examination. (6) I am currently enrolled in an approved Workers' Comp program. (I agree, if appropriate.) DWC AD 10133.53(2)(2) AN OFFER OF PAYMENT AND CERTIFICATION WITHIN FIVE (5) DAYS If I am not enrolled in an approved Workers' Comp program within the five (5) days following a claim, my Employer reserves the right to proceed (1) in person (2) by mail, and/or (3) by telephone, as provided by the DWC. I certify that my Employer has sent me (Employee name) to sign a form for this offer within the space provided: DWC AD 10133.53(2)(5) AN OFFER OF PAYMENT AND CERTIFICATION WITHIN ONE (1) DAY, AND A CLAIM FOR COMPENSATION AND A CLAIM FOR MEDICAL FEE AN OFFER OF PAYMENT AND CERTIFICATION WITHIN NINETY-FIRST DAYS If the claim for compensation or medical fee has not yet been made, this offer is effective up to one (1) morning after the first work day following the date of the claim.
CA DWC-AD 10133.53(SJDB) 2008 free printable template
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Print Form Reset Form State of California Division of Workers' Compensation Retraining and Return to Work Unit NOTICE OF OFFER OF MODIFIED OR ALTERNATIVE WORK For injuries occurring on or after 1/1/04
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