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The Workers’ Compensation Appeals Board (WCAB) and the Division of Workers’ Compensation (DWC) have created a new form and made modifications to two existing forms for use in the Electronic Adjudication Management System (EAMS). The new and modified forms will be posted on DWC’s website today. The changes were necessitated by SB 863. The forms are:

• DWC-CA 10214 a-1 [Stipulations with Request for Award (Rev. 4/2014)]
• DWC-CA 10208.3 [Declaration of Readiness to Proceed (Expedited Trial) (Rev. 4/2014)]
• DWC–CA 10232.2 [Document Separator Sheet]

The DWC-CA 10214 a-1 [Stipulations with Request for Award DOI post 1-1-2013 (Rev. 4/2014)] is a new form to be used for injuries on or after January 1, 2013. Pursuant to SB 863, the 15 percent increase or decrease in permanent disability under Labor Code 4658(d) has been eliminated. This form is used by e-form filers and it is now available for use by OCR filers. The old form will be accepted for OCR filing for injuries on or after January 1, 2013 until October 1, 2014. At a later date, the revised form will be placed in use for JET filers.

The current form DWC-CA 10214(a) [Stipulations with Request for Award (Rev 11/2008)] remains in use for e-form and OCR filers for injuries before January 1, 2013. JET filers will continue to use this form for all dates of injury.  

The DWC-CA 10208.3 [Declaration of Readiness to Proceed (Expedited Trial) (Rev. 4/2014)], which is used for expedited trials, was also modified. Medical treatment issues are limited to those not arising out of utilization review. Medical Provider Network (MPN) issues for medical treatment purposes have been added. Vocational rehabilitation appeal has been removed. This form is in use for e-form filers and it is now available for use by OCR filers. The older version of this form will be accepted for OCR filing until October 1, 2014. At a later date, the new form will be placed in use for JET filers.

DWC-CA 10232.2 [Document Separator Sheet] (Rev. 4/2014) for OCR filing also updates the document types and titles used for OCR filers and the Unstructured E-form. At a later date it will be placed in use for JET filers. 

The modifications to existing document types or document titles are posted in the DWC website. These changes to document types and titles are in use for OCR and e-form filers currently. The older version of this form will be accepted for OCR filing until October 1, 2014.

State of California Department of Industrial Relations, P.O. Box 420603, San Francisco, CA 94142-0603 www.dir.ca.gov