WORKERS' COMPENSATION APPEALS BOARD STATE OF CALIFORNIA W.C.A.B. CASE NOS. (Applicant) vs. (Defendants) MINUTES OF HEARING/APPEARANCE SHEET ORDER AND DECISION ON REQUEST FOR CONTINUANCE OR OFF CALENDAR DEFENDANTS/LIEN CLAIMANTS Print Name: Atty/H.R./P.P. Sign For DISCOVERY NOW CLOSED [EXCEPT: The parties acknowledge receipt (service) of documentary evidence per paragraphs 18 and 19 of Pretrial Stipulations. (Defendants) (Lien Claimant ) to serve notice of the above continued date on all defendants/unsatisfied lien claimants not present. AGREED: (Person responsible) Motion for Continuance, Adjournment to submit settlement or off calendar made by: Reason for motion: Position of opposing party: Good Cause: IT IS ORDERED THAT this case is: Continued for Lien Conference Before the Undersigned At this WCAB Branch on Lien Trial Before the Honorable, at 8:30 A.M./1:30 P.M. Order(s) Issued/OTOC HEARING NOTES Submitted ] NOTICE TO Pursuant to Rule 10500, you are designated to serve this/these documents on all parties as set forth in P and P Section 6.7.4, 10-1-95. SO ORDERED: HONORABLE Date: 1 WCAB-105
GENERAL MATTERS ABOUT LIEN CONFERENCE/TRIAL PROCEEDINGS PLEASE NOTE 1. At a lien conference if continuing to another lien conference, please be sure the agreement to serve absent parties near the bottom of the Minutes/Appearance form is completed before you come in. If on trial calendar you may seek leave to interrupt a trial proceeding to get a disposition signed. 2. If continuing from a lien conference to a trial setting, please complete the Pre-Trial Stipulations form and Issues and Contentions form, and set up exhibits on a backer in the manner described in the Exhibits Offered sheet. Please list your witnesses on the Witness List. Exhibits and Witnesses MUST BE LISTED on each party's Exhibit List and Witness List. 3. Please use only the attached forms and be sure all parties present: (a) sign at the bottom of Pre-Trial Stipulations and (b) someone signs the agreement near the bottom of the Minutes/Appearance form to serve all other absent parties. (c) each party signs Paragraphs 18 and 19 of Pre-Trial Stipulations acknowledging service and any duty to serve. 4. Normally, notices of intention to disallow or grant in whole or part will be signed based on the merits. Notice of intent to dismiss will not issue based on nonappearance alone. 5. When coming in to see judge just before trial, be familiar with your case and documents BEFORE coming in to see the judge if you have not reached a disposition. See the Documents Needed for Discussions/Conference/Trial. 6. Discovery is NOW CLOSED unless the Minutes of [this] Hearing have written order(-s) relating to discovery closure. 2
DOCUMENTS NEEDED FOR DISCUSSION/CONFERENCE/TRIAL Please bring the following documents to substantiate your contentions: 1. All Claim Forms and Applications for all dates of injuries (by case number) and any other evidence as to when employer had knowledge of the claim(s). a. Know parts of body for each date of injury. 2. The C&R with order approving or Stips and Award. 3. Documents relating to WHEN and WHY Applicant stopped work. 4. Delay and denial letters. 5. List of all charges. 6. All relevant medical reports; be familiar with what they say. 7. All "notice" letters. 8. All "objection" letters. 9. All reviews of lien charges. 10. All relevant proof of services. 11. If a deposition or other transcript is to be used, know pages and line numbers of relevant portions to be used. 12. If medical records, subpoenaed or otherwise obtained, are to be relied upon, have the relevant portions identified and know why they are relevant. PLEASE NOTE: (1) You should be familiar with all documents BEFORE you come into our offices. (2) Original documents, including proofs of service, should be available for viewing. 3
WORKERS' COMPENSATION APPEALS BOARD STATE OF CALIFORNIA W.C.A.B. CASE NO.(S) vs. [Unless virtually identical: one for each injury, please] PRE-TRIAL STIPULATIONS 1. (was) (allegedly was not) employed (Employee) within the State of California on by (Employer) (whose compensation insurance carrier was then ). (alleged date or period of injury) (then permissibly self-insured) 2. The employee (did) (allegedly did not) sustain industrial injury (on that date) (during that period). 3. The following parts of the body were industrially injured on the date or period mentioned in paragraph 1:. 4. The industrial injury involved the following body parts: and allegedly the following additional parts:. 5. The employee's actual earnings were ($ per week) (such as to produce indemnity at a rate exceeding EDD payment rate). 6. Issues of occupation, birthdate and rehabilitation are moot. 7. (A) All medical treatment furnished was the result of the injury. (B) All medical treatment furnished, except that by (lien claimant(s)) was due to the injury. 4
(C) All medical treatment, except that to (body parts) was the result of the industrial injury. (D) Such of the above treatment as resulted from the industrial injury was necessarily incurred: (yes) (in issue) (E) All medical treatment resulting from the industrial injury was necessarily incurred except that of: (F) Per Paragraph 7(A) - 7(E) the medical treatment resulting from the injury and necessarily incurred, was actually rendered: (yes) (in issue) 8. Last day worked: Lien claimants allege: Defendants allege: 9. Reason stopped work (please include what you're basing this on): Lien claimant alleges: Defendants allege: 10. Employer's first date of knowledge that industrial injury occurred (and what it's based on): Lien claimant alleges: Defendants allege: 5
11. Type of settlement (with amount and whether or not any Thomas finding was made) or Findings and Award/Order were made: (Stip for F&A) (C&R: $ Thomas Finding: (yes) (no) ) (Findings & Award/Order); 12. Date of Medical Services Provided: Please indicate M/L, Treatment Date or Both Specialty Name MD or Provider Service Provided Amount Claimed $ [additional: please attach a separate sheet] 6
13. Dates of each delay letter 14. Dates of each denial letter 15. Dates of each objection letter 16. Additional Stipulations: 17. DID you list all exhibits (including claim forms, delay, denial and objection letters, bills, liens, medical reports and records and transcripts or other documents) and list all proposed witnesses on Exhibit List and Witness List? 18. The parties hereby STIPULATE to the matters in these Pretrial Stipulations. They ALSO stipulate they have been served with all documentary evidence listed by the opposing party in the opposing party's Exhibit List EXCEPT AS NOTED in Paragraph 19. For For For 19. (a). Defendants agree to serve the following documents forthwith on: (all signing lien claimants). ( (name specific lien claimants) ) 7
(b). Defendants agree to serve (all absent unsatisfied lien claimants) (the following) with all documents on defendants' Exhibit List: (c). Lien claimant(s) agree(s) to serve defendants with the following documents forthwith: (d). Lien claimant agrees to serve (all absent unsatisfied lien claimants) (the following lien claimants) with all documents on Lien Claimants' Exhibit List(s):. DISCOVERY IS NOW CLOSED UNLESS WRITTEN ORDER TO THE CONTRARY IS NOW MADE BY THE COURT ON THE MINUTES OF HEARING/APPEARANCE SHEET. [Please use lined, ruled paper as an addendum for additional liens and/or other information for which space is lacking] 8
WORKERS' COMPENSATION APPEALS BOARD STATE OF CALIFORNIA CASE NO.(S): vs. ISSUES & CONTENTIONS OF (Party or Lien Claimant) This form is to list the general and specific issues or legal contentions to be considered by the COURT. Attach any Points and Authorities to this form. Each side needs to use a separate page. PLEASE PRINT Signed: For: 9
EXHIBITS OFFERED BY: (Defendants) (Lien Claimant ) This form is to list all documentary evidence relied upon. It will constitute your evidence of record. Do not use this form for arguments, points and authorities or objections. Each party should fill in their own Exhibit List and Witness List. PLEASE LIST EVERYTHING AND PLACE IN REVERSE CHRONOLOGICAL ORDER. KINDLY PRINT EVERYTHING. THIS DOCUMENT IS TO BE PLACED ON TOP OF YOUR EXHIBITS. Medical reports, bills, liens, delay, denial and objection letters, claim forms or any other documents should be arranged in reverse chronological order (by date of report, not examination, if different) with the most current report on top, next current just below, etc. Extra copies should be discarded. LIEN CLAIMANTS: Did you list LAST AMENDED LIEN (or fill out and submit one) and LIST & ATTACH BILL OR BILLS SUPPORTING THE SERVICES, TESTS, ETC. shown in final amended line? IN FINAL AMENDED LIEN. These have to be offered as EXHIBITS TOGETHER WITH ANY MEDICAL REPORTS OR RECORDS, TRANSCRIPTS, CLAIM FORMS OR OTHER DOCUMENTS? DEFENDANTS: DID YOU INCLUDE CLAIM FORMS, DELAY, DENIAL AND OBJECTION LETTERS, MEDICAL REPORTS OR RECORDS, TRANSCRIPTS OR OTHER DOCUMENTS? PARTIES: IF TRANSCRIPTS OR MEDICAL RECORDS ARE OFFERED, PLACE COPIES OF PAGES YOU WANT THE COURT TO CONSIDER ON TOP OF THE TRANSCRIPT OR RECORDS IN QUESTION. 10
EXHIBIT LIST Description of Document Date Description Date The party signing below certifies that all exhibits listed are attached to this document [unless otherwise noted as being filed by trial]. It also is certified that the listed exhibits have been served on all opposing parties [UNLESS judicial permission to the contrary has been received in writing]. Dated: Signed: 11
WITNESS LIST CASE NO(S): (Employee Name) WITNESS LIST OF: (Defendants) (Lien claimant: ) Witnesses Who May Be Called: 12