Get the free DWC-AD form 10120 (SJDB)

Print Forrest Formulate of California Division of Workers Compensation Retraining and Return to Work Unit Request for Reimbursement of Accommodation Expenses For injuries on or after July 1, 2004,

How to fill out dwc-ad form 10120 sjdb

How to fill out dwc-ad form 10120 sjdb

1. To fill out the DWC-AD form 10120 SJDB (Supplemental Job Displacement Benefit Voucher), follow these steps:
2. Start by obtaining the form. You can download it from the official website of the Division of Workers' Compensation (DWC) or request a copy from your employer or workers' compensation insurance carrier.
3. Read the instructions carefully to understand the purpose and requirements of the form.
4. Fill in your personal information, including your name, address, and contact details.
5. Provide the name of your employer and the address of your workplace at the time of the injury.
6. Indicate the date of your injury and the body part affected.
7. Describe the circumstances of the injury and provide any additional details requested on the form.
8. If you have received any medical treatment related to the injury, specify the name of the healthcare provider and the dates of treatment.
9. Sign and date the form.
10. Keep a copy of the completed form for your records.
11. Submit the filled-out form as instructed by your employer or workers' compensation insurance carrier.
12. Note: It is recommended to consult with an attorney or a qualified professional when filling out this form to ensure accuracy and compliance with legal requirements.

Who needs dwc-ad form 10120 sjdb?

1. The DWC-AD form 10120 SJDB is required by individuals who have sustained a work-related injury and may be eligible for the Supplemental Job Displacement Benefit (SJDB) voucher. This voucher helps provide assistance in obtaining new skills or education to enhance employment prospects for individuals who cannot return to their previous job due to their injuries. Eligibility for the SJDB voucher is determined by the treating physician and the provisions of the workers' compensation system. Therefore, injured workers who meet the criteria for the SJDB voucher need to complete and submit the DWC-AD form 10120 SJDB to initiate the process.

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What is dwc-ad form 10120 sjdb?

The DWC-AD form 10120 SJDB is a form used in California for the submission of a supplemental job displacement benefit, which is part of the workers' compensation program.

Who is required to file dwc-ad form 10120 sjdb?

Employers are required to file the DWC-AD form 10120 SJDB when an employee is injured and is eligible for supplemental job displacement benefits after their claim has been accepted.

How to fill out dwc-ad form 10120 sjdb?

To fill out the DWC-AD form 10120 SJDB, one must provide information such as the injured worker's details, information about the employer, the specifics of the injury, and a description of the job displacement benefits.

What is the purpose of dwc-ad form 10120 sjdb?

The purpose of the DWC-AD form 10120 SJDB is to provide documentation for injured workers to receive supplemental job displacement benefits, which assist them in finding new employment after a work-related injury.

What information must be reported on dwc-ad form 10120 sjdb?

The DWC-AD form 10120 SJDB must report the employee's name, contact information, claim number, injury details, and the employer's information, as well as the amount of benefits being claimed.