Get the free DWC-AD form 10118 (SJDB)

Print Form Reset Form State of California Division of Workers' Compensation Retraining and Return to Work Unit NOTICE OF OFFER OF REGULAR WORK For injuries occurring on or after 1/1/05 DWC AD 10118

How to fill out dwc-ad form 10118 sjdb

How to fill out DWC-AD form 10118 SJDB:

1. Start by carefully reading the instructions provided with the form. This will give you a clear understanding of the information required and how to accurately fill it out.
2. Begin by providing your personal information such as your name, contact details, and the date of the incident or injury.
3. Next, you will need to provide details about your employer, including their name, address, and contact information.
4. The form will ask for information regarding your treating physician or healthcare provider. Include their name, address, and contact details.
5. Explain the nature and extent of your injury or illness in detail. Provide specific information about the body parts affected and the circumstances surrounding the incident.
6. If you have received medical treatment related to the injury, provide accurate details about the healthcare services you have received, including the dates, type of treatment, and the name of the healthcare provider or facility.
7. Indicate whether you have been offered work by the employer. If so, provide details about the job offer, such as the position, hours, rate of pay, and any restrictions or accommodations.
8. If you have any other pertinent documents or evidence related to your injury or the incident, attach them to the form as instructed.
9. Carefully review the completed form to ensure all the required information is provided and that it is accurate and legible.
10. Sign and date the form, certifying that the information provided is true and correct to the best of your knowledge.

Who needs DWC-AD form 10118 SJDB?

1. Employees who have been involved in a workplace injury or have suffered a work-related illness may need to fill out DWC-AD form 10118 SJDB.
2. This form is specifically designed for individuals seeking assistance or benefits under the Supplemental Job Displacement Benefit (SJDB) program in California.
3. The SJDB program provides eligible employees with vouchers that can be used for retraining or skill enhancement to secure a new job if they are unable to return to their previous employment due to their work-related injury or illness.

For pdfFiller’s FAQs

What is dwc-ad form 10118 sjdb?

DWC-AD form 10118 SJDB stands for Division of Workers' Compensation - Supplemental Job Displacement Benefit form. It is a form used in California's workers' compensation system to request assistance for job displacement benefits.

Who is required to file dwc-ad form 10118 sjdb?

The injured worker who is eligible for Supplemental Job Displacement Benefits (SJDB) is required to file the DWC-AD form 10118 SJDB.

How to fill out dwc-ad form 10118 sjdb?

To fill out the DWC-AD form 10118 SJDB, you need to provide personal information, such as name and contact details, information about your injury and workers' compensation claim, the employer's information, and any vocational rehabilitation or job training expenses you have incurred or expect to incur.

What is the purpose of dwc-ad form 10118 sjdb?

The purpose of the DWC-AD form 10118 SJDB is to request assistance for job displacement benefits under California's workers' compensation system. These benefits aim to help injured workers who cannot return to their pre-injury job find and train for new employment.

What information must be reported on dwc-ad form 10118 sjdb?

The DWC-AD form 10118 SJDB requires information such as the injured worker's personal details, injury details, employer information, and vocational rehabilitation or job training expenses.

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