Get the free DWC-AD form 10133.57 (SJDB)

Reset Footprint Formulate of California Division of Workers Compensation Retraining and Return to Work Unit SUPPLEMENTAL JOB DISPLACEMENT NONTRANSFERABLE TRAINING VOUCHER FORM DWC AD 10133.57 Injured

How to fill out dwc-ad form 1013357 sjdb

How to fill out dwc-ad form 1013357 sjdb

1. To fill out the DWC-AD form 1013357 SJDB, follow these steps:
2. Obtain the form: You can get the form from the official website of the California Division of Workers' Compensation (DWC) or contact your employer or workers' compensation insurance carrier for a copy.
3. Read the instructions: Carefully read the instructions provided with the form to understand the requirements and guidelines for filling it out correctly.
4. Provide personal information: Fill in your personal details such as name, address, phone number, and social security number.
5. Describe the injury: Describe the details of your work-related injury or illness, including the date, time, location, and circumstances of the incident.
6. Medical treatment information: Provide information about the medical treatment you have received for your injury, including the names of doctors or healthcare providers.
7. Employer information: Fill in the details of your employer, including the company name, address, and contact information.
8. Employment information: Provide information about your job, such as your job title, duties, and salary at the time of the injury.
9. Additional documentation: Attach any supporting documentation, such as medical reports, bills, or wage statements.
10. Review and sign: Review the completed form for accuracy, then sign and date it.
11. Submit the form: Send the completed form to the appropriate party as instructed by the DWC or your employer.

Who needs dwc-ad form 1013357 sjdb?

1. The DWC-AD form 1013357 SJDB is required for individuals who have suffered a work-related injury or illness and are seeking compensation under the California workers' compensation system. This form specifically applies to individuals who are eligible for the Supplemental Job Displacement Benefit (SJDB) voucher. The voucher provides assistance for retraining and skill enhancement to help injured workers return to suitable employment after their injury. Therefore, anyone who meets the eligibility criteria for SJDB and wishes to utilize this benefit needs to fill out the DWC-AD form 1013357 SJDB.

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What is dwc-ad form 1013357 sjdb?

DWC-AD Form 1013357 SJDB is a 'Supplemental Job Displacement Benefits' form used in California for workers who have been injured on the job and are entitled to job displacement benefits under the state's workers' compensation system.

Who is required to file dwc-ad form 1013357 sjdb?

Employers are required to file DWC-AD Form 1013357 SJDB when an employee who has suffered a work-related injury is entitled to supplemental job displacement benefits.

How to fill out dwc-ad form 1013357 sjdb?

To fill out DWC-AD Form 1013357 SJDB, you need to provide the injured employee's information, details of the injury, the duration of benefits received, and any relevant job displacement information. Follow the form instructions carefully.

What is the purpose of dwc-ad form 1013357 sjdb?

The purpose of DWC-AD Form 1013357 SJDB is to document that an injured worker is entitled to supplemental job displacement benefits and to provide a formal request for those benefits to be issued.

What information must be reported on dwc-ad form 1013357 sjdb?

The information that must be reported includes the employee's name, address, date of birth, details of the injury, dates of employment, and any training or education information that applies to the job displacement.