Fillable State of California Division of Workers' Compensation NOTICE (California)

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State of California Division of Workers' Compensation NOTICE (California)

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State of California
Division of Workers' Compensation
NOTICE OF OFFER OF REGULAR, MODIFIED, OR ALTERNATIVE WORK
FOR INJURIES OCCURRING ON OR AFTER 1/1/13
DWC - AD 10133.35
THIS SECTION COMPLETED BY CLAIMS ADMINISTRATOR (All information in this section must be completed):
You have 30 calendar days from receipt to accept or reject the attached offer of work. However, if you fail to respond in
30 days or reject this job offer, you will not be entitled to the supplemental job displacement benefit unless the offer is for
modified work or alternative work and:
A. You cannot perform the essential functions of the job; or
B. The job is not a regular position lasting at least 12 months; or
C. Wages and compensation offered are less than 85% paid at the time of injury; or
D. The job is beyond a reasonable commuting distance from residence at time of injury.
Claims Administrator Type: (Please Choose One)
DWC-AD form 10133.35 (SJDB) Eff: 1/1/14 - Page 1 of 4
MM/DD/YYYY MM/DD/YYYY
Name of Job
(Choose only one)
and ended of
MM/DD/YYYY
Insurance Company
Third Party Administrator Employer
Employer Name
is offering you
the position of a
You may contact
concerning this offer. Phone No.:
Date of offer: Date job starts:
Date of Birth:
(END DATE: MM/DD/YYYY)
(START DATE: MM/DD/YYYY)
MM/DD/YYYY
a specific injury on
a cumulative trauma injury which began on
Claims Administrator
Claims Representative
Claim Phone Number
Claims Address
Claim Number:
This offer is for:
Regular Work
Modified Work Alternative Work
(Employee Name)
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POSITION REQUIREMENTS
Is salary of regular/modified/alternative work the same as pre-injury job?
Is salary of regular/modified/alternative work at least 85% of pre-injury job?
Is job expected to last at least 12 months?
Is the job a regular position required by the employer's business?
DWC-AD form 10133.35 (SJDB) Eff: 1/1/14 - Page 2 of 4
Yes No
Wages: $
Yes
No
Actual job title:
Yes
No
Work location:
Duties required of the position:
Description of activities to be performed (if not stated in job description):
Yes
No
Per hour Week
Month
Position is for a different shift.
Same as Pre-Injury Position
The shift time is
(Start Time) (End Time)
-
Year
If the job offered is at a different location than the job you held at the time of your injury, and you believe the commuting
distance to this job from the residence where you lived at the time of your injury is not reasonable, you may object to the job offer
as not being within a reasonable commuting distance.
You may also waive this commuting distance requirement. You will be considered to have waived this requirement if you
accept the above offer of work or do not reject the offer within twenty calendar days of receipt of this notice. The employee
should keep a copy of this form for his or her records.
I accept the offer and waive any right to object to the job location or shift as not being within a reasonable commuting
distance from the residence where I lived at the time of my injury.
MM/DD/YYYY
DWC-AD form 10133.35 (SJDB) Eff: 1/1/14 - Page 3 of 4
Physical requirements for performing work activities (include modifications to usual and customary job):
Name of doctor who approved job restrictions (optional):
Date of report:
PTP QME AME
Print Name:
by placing a true copy thereof enclosed in a sealed envelope with postage thereon fully paid, in the United States mail.
Signature:
, CA.
was exectuted on:
I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct, and that this
declaration
by personal service.
I served the attached on:
,
I declare that: On
Proof of Service by Mail
(To Be Completed By the Employer or Claims Administrator)
at
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DWC-AD form 10133.35 (SJDB) Eff: 1/1/14 - Page 4 of 4
I feel I cannot accept this offer because:
MM/DD/YYYY
Date:Signature:
I understand that if I voluntarily quit prior to working in this position for 12 months, I may not be entitled to the Supplemental Job
Displacement Benefit.
I accept this offer of Regular, Modified, or Alternative work.
I reject this offer of Regular, Modified, or Alternative work and understand that I may not be entitled to the
Supplemental Job Displacement Benefit.
THIS SECTION TO BE COMPLETED BY EMPLOYEE (All information in this section must be completed)
If a dispute occurs regarding the above offer or agreement, either party may request the Administrative Director to
resolve the dispute by filing a Request for Dispute Resolution (Form DWC-AD 10133.55) with the Administrative Director, Division
of Workers' Compensation, P.O. Box 420603, San Francisco, CA 94142-0603.
If the offer is not accepted or rejected within 30 days of receipt of the offer, the offer is deemed to be rejected by the
employee.
NOTICE TO THE PARTIES
I object to this offer because the job location that has been offered is different than the job location I held at the time of my
injury, and I do not believe this job allows a reasonable commute from my residence.
I understand that this offer is expected to last at least 12 months. If seasonal work is being offered, I understand that the 12
months may be satisfied by cumulative periods of seasonal work. In the event this position ends or I am laid off prior to working
12 months, I understand that I may be entitled to the Supplemental Job Displacement Benefit.
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State of California Division of Workers' Compensation NOTICE (California)

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Completed 24 February 2022

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