Form 10133.35 - State Of California Page 4
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4THIS SECTION TO BE COMPLETED BY EMPLOYEE (All information in this section must be completed)
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.
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.
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 feel I cannot accept this offer because:
Signature:
Date:
MM/DD/YYYY
NOTICE TO THE PARTIES
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.
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.
DWC-AD form 10133.35 (SJDB) Eff: 1/1/14 - Page 4 of 4
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