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The California Division of Workers’ Compensation (DWC) has posted a revised Supplemental Job Displacement Benefit voucher form on its website. The voucher form has been updated to conform to Title 8, California Code of Regulations, section 17303.

The Return-to-Work Supplement Program makes supplemental payments to workers whose permanent disability benefits are disproportionately low in comparison to their earnings losses. To be eligible for the fund, an applicant must have a date of injury on or after January 1, 2013 and have received a Supplemental Job Displacement Benefit voucher.

The following notice has been added to the first page of the voucher:

“Because you have received this Voucher and are unable to return to your usual employment, you may be eligible for a Return-to-Work Supplement. You must apply within one year from the date this Voucher was served on you. You should make a copy of the Voucher which you will need to apply for the Return-to-Work Supplement. Details about the Return-to-Work supplement program are available from the Department of Industrial Relations on its website, www.dir.ca.gov, or by calling 510-286-0787.”

Claims administrators must use the updated form and no longer need to attach a cover sheet with the above notice to the vouchers when they are issued to injured workers.

The updated form is currently effective and can be found here.

California Department of Industrial Relations * www.dir.ca.gov *