CA DWC Form 10214 2008-2025 free printable template

Reset Form STATE OF CALIFORNIA DIVISION OF WORKERS COMPENSATION WORKERS COMPENSATION APPEALS BOARD COMPROMISE AND RELEASE Case Number 1 SSN Numbers Only Venue Choice is based upon Completion of this section is required County of residence of employee Labor Code section 5501. Unless otherwise expressly stated approval of this agreement RELEASES ANY AND ALL CLAIMS OF APPLICANT S DEPENDENTS TO DEATH BENEFITS RELATING TO THE INJURY OR INJURIES COVERED BY THIS COMPROMISE AGREEMENT. The parties...

How to fill out ca form 10214

How to fill out CA DWC Form 10214

1. Begin by downloading the CA DWC Form 10214 from the California Division of Workers' Compensation website.
2. Fill out the 'Employee Information' section, including the employee's name, address, and contact information.
3. Provide details about the employer in the 'Employer Information' section, such as the company name, address, and contact details.
4. In the 'Claim Information' section, enter the date of the injury, the nature of the injury, and any relevant claim numbers.
5. Complete the 'Medical Provider Information' section with the physician's name, address, and contact information.
6. Sign and date the form at the designated area to certify that the information provided is accurate.
7. Submit the completed form to the appropriate claims administrator or department as specified in the instructions.

Who needs CA DWC Form 10214?

1. Any employee in California who has suffered a work-related injury or illness and is filing for workers' compensation benefits needs to complete the CA DWC Form 10214.
2. Employers who are involved in the workers' compensation claim process must also complete and submit this form.

Video instructions and help with filling out and completing compromise release fillable

Instructions and Help about CA DWC Form 10214

As you have learned from previous videos there are two types of settlements of workers compensation claims first the stipulations keeping your future medical care open and the second is a compromise and release a buyout of your future medical and essentially all other costs related to your workers compensation claim this is a clean split between you the insurance carrier and usually your employer as well we won't go into the ins and outs of each type as we already done so in previous videos negotiating may sound intimidating at first but once you know your key negotiating points and are looking for a reasonable settlement this can be a relatively painless process that will leave you with a lot more money than originally offered I advise that you watch the negotiation settlements via stipulations video prior to watching this video in order to learn how to negotiate the permanent disability percentage aspect of the settlement in this video we'll go over key bargaining points for a compromise and release settlement in which the insurance company will be paying you a lump sum award in order to buy out the permanent disability future medical care you're entitled to and essentially any and all costs associated with the claim including possibly your employment status the last part is a key factor to remember when thinking about your settlement value let's start off by using an example say you had a knee injury at work you treated and eventually had a knee arthroscopy and you are now deemed permanent and stationary by your primary treating physician your recovery went okay and your doctor dictated a report stating you have a 12% permanent disability rating which is equivalent to about seven thousand eight hundred and seventy seven dollars and fifty cents and he also stated that you're entitled the future medical in the event that you have an aggravation or flare-up of your injury a doctor states specifically you are entitled to orthopedic visits pain medications a new MRI a knee brace every year and possibly even a future knee arthroscopy now an important point here is to ensure that you understand this is essentially for your entire lifetime of course you may not actually treat for every year in your whole life but keeping in mind that you're entitled to it based on the report you can use this as a bargaining tool when trying to negotiate ACN are in ACN are the baseline value is the permanent disability percentage you're given this is essentially the lowest amount of money you would receive and you can learn how to negotiate this value in the prior video negotiation settlements via stipulations in any case say you were successful and we're able to negotiate a pd value up to 18 percent which is approximately fifteen thousand dollars we'll use this as our baseline next up comes the future medical value and here there's a lot of gray area unfortunately that leads to more negotiation power to you so to understand this process we'll first go into how the...

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What is CA DWC Form 10214?

CA DWC Form 10214 is a document used in California's workers' compensation system, specifically for reporting claims for workers who have sustained injuries or illnesses related to their employment.

Who is required to file CA DWC Form 10214?

Employers in California who have employees that have experienced work-related injuries or illnesses are required to file CA DWC Form 10214 with the California Division of Workers' Compensation.

How to fill out CA DWC Form 10214?

To fill out CA DWC Form 10214, employers need to provide information about the injured employee, including personal details, injury information, and any medical treatments received. It's important to follow the instructions provided with the form for accurate completion.

What is the purpose of CA DWC Form 10214?

The purpose of CA DWC Form 10214 is to formally document a workers' compensation claim and to ensure that the injured employee receives the necessary medical treatment and benefits due to their workplace injury or illness.

What information must be reported on CA DWC Form 10214?

The information that must be reported on CA DWC Form 10214 includes the employee's name, address, social security number, date of birth, details of the work injury, date of injury, employer's information, and any medical treatment received.