Form 10133.35 - State Of 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):
Claims Administrator Type: (Please Choose One)
Third Party Administrator
Employer
Insurance Company
is offering you
Employer Name
(Employee Name)
the position of a
Name of Job
This offer is for:
Regular Work
Modified Work
Alternative Work
You may contact
concerning this offer. Phone No.:
Date of offer:
Date job starts:
MM/DD/YYYY
MM/DD/YYYY
Claims Administrator
Claims Representative
Claim Phone Number
Claims Address
Claim Number:
(Choose only one)
a specific injury on
MM/DD/YYYY
a cumulative trauma injury which began on
and ended of
(START DATE: MM/DD/YYYY)
(
END DATE: MM/DD/YYYY)
Date of Birth:
MM/DD/YYYY
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.
DWC-AD form 10133.35 (SJDB) Eff: 1/1/14 - Page 1 of 4
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