Fillable Dwc-Ca Form 10214 - Compromise And Release

Dwc-Ca Form 10214 - Compromise And Release - 2008 Page 3

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Claims Administrator Information (if known and if applicable)

Name (Please leave blank spaces between numbers, names or words)

Street Address/PO Box (Please leave blank spaces between numbers, names or words)

State

City

Zip Code

IT IS CLAIMED THAT:

1. The injured employee, born

, alleges that while employed as a(n)

(DATE OF BIRTH: MM/DD/YYYY)

, sustained injury

(OCCUPATION AT THE TIME OF INJURY)

arising out of and in the course of employment at the locations and during the dates listed below:

(State with specificity the date(s) of injury(ies) and what part(s) of body, conditions or systems are being settled.)

Specific Injury

(Start Date: MM/DD/YYYY)

(End Date: MM/DD/YYYY)

Case Number 1

Cumulative Injury

(If Specific Injury, use the start date as the specific date of injury)

Body Part 1:

Body Part 2:

Body Part 3:

Body Part 4:

Other Body Parts:

The injury occurred at

(Street Address/PO Box - Please leave blank spaces between numbers, names or words)

Zip Code

City

State

Body parts, conditions and systems may not be incorporated by reference to medical reports.

DWC-CA form 10214 (c) (Rev. 11/2008) (Page 3 of 9)

Dwc-Ca Form 10214 - Compromise And Release - 2008 Page 3

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