Form I&A9 "How to File a Petition for Commutation" - California

What Is Form I&A9?

This is a legal form that was released by the California Department of Industrial Relations - Division of Workers' Compensation - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on November 1, 2019;
  • The latest edition provided by the California Department of Industrial Relations - Division of Workers' Compensation;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form I&A9 by clicking the link below or browse more documents and templates provided by the California Department of Industrial Relations - Division of Workers' Compensation.

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Information & Assistance Unit guide 9
How to file a petition for commutation
This form should be filed if you received an award of permanent disability and you
want all or part of your award paid in a lump sum. An award of permanent
disability is only issued by a workers’ compensation judge.
A summary rating from the Disability Evaluation Unit is not an award of permanent
disability.
You will need to prove you have a financial hardship to get your award in a lump
sum.
Send the original to your local WCAB office and copies to all the parties.
Submit the following documents with your form filing in the order shown:
Document Cover Sheet
Document Separator Sheet
(for Petition Commutation)
Petition for Commutation
 Verification
Document Separator Sheet
(for Proof of Service By Mail)
Proof of Service By Mail
Keep copies of your filings for your records.
All documents filed with the WCAB must include a document cover sheet and
document separator sheet.
Please see I&A guides 17 and 18 to learn how to
complete these forms.
In addition all forms must be typed or handwritten in
block letters to insure legibility. Additional form instructions can be found on the
EAMS OCR handbook at
http://www.dir.ca.gov/dwc/eams/SampleFiles/EAMS_OCR%20handbook.pdf.
If you need help, call an
Information and Assistance (I&A)
office, or attend a
workshop for injured
workers. The local I&A phone numbers are attached to this
guide. You can get information on a local workshop from the I&A office or on the
Web at www.dwc.ca.gov.
If you do not have the name and address of your insurance company to
complete a form, please link to
http://www.dir.ca.gov/DWC/EAMS/EAMS-
LC/EAMSClaimsAdmins.asp.
The information contained in this guide is general in nature and is not intended as a substitute for
legal advice. Changes in the law or the specific facts of your case may result in legal
interpretations different than those present here.
When sending documents to a district office, please make sure they are not folded or stapled.
Send them in a large manila envelope. Please see the EAMS OCR forms handbook for further
instructions.
I&A 9
Rev. 06/18
Information & Assistance Unit guide 9
How to file a petition for commutation
This form should be filed if you received an award of permanent disability and you
want all or part of your award paid in a lump sum. An award of permanent
disability is only issued by a workers’ compensation judge.
A summary rating from the Disability Evaluation Unit is not an award of permanent
disability.
You will need to prove you have a financial hardship to get your award in a lump
sum.
Send the original to your local WCAB office and copies to all the parties.
Submit the following documents with your form filing in the order shown:
Document Cover Sheet
Document Separator Sheet
(for Petition Commutation)
Petition for Commutation
 Verification
Document Separator Sheet
(for Proof of Service By Mail)
Proof of Service By Mail
Keep copies of your filings for your records.
All documents filed with the WCAB must include a document cover sheet and
document separator sheet.
Please see I&A guides 17 and 18 to learn how to
complete these forms.
In addition all forms must be typed or handwritten in
block letters to insure legibility. Additional form instructions can be found on the
EAMS OCR handbook at
http://www.dir.ca.gov/dwc/eams/SampleFiles/EAMS_OCR%20handbook.pdf.
If you need help, call an
Information and Assistance (I&A)
office, or attend a
workshop for injured
workers. The local I&A phone numbers are attached to this
guide. You can get information on a local workshop from the I&A office or on the
Web at www.dwc.ca.gov.
If you do not have the name and address of your insurance company to
complete a form, please link to
http://www.dir.ca.gov/DWC/EAMS/EAMS-
LC/EAMSClaimsAdmins.asp.
The information contained in this guide is general in nature and is not intended as a substitute for
legal advice. Changes in the law or the specific facts of your case may result in legal
interpretations different than those present here.
When sending documents to a district office, please make sure they are not folded or stapled.
Send them in a large manila envelope. Please see the EAMS OCR forms handbook for further
instructions.
I&A 9
Rev. 06/18
 
 
 
 
 
 
 
 
 
 
 
 
WORKERS’ COMPENSATION APPEALS BOARD DISTRICT OFFICES
ANAHEIM, 92806-2131
SACRAMENTO, 95834-2962
1065 N Link, Suite 170
160 Promenade Circle, Suite 300
Information & Assistance Unit (714) 414-1801
Information & Assistance Unit (916) 928-3158
BAKERSFIELD, 93301-1929
SALINAS, 93906-2204
th
1880 N Main Street, Suites 100 & 200
1800 30
Street, Suite 100
Information & Assistance (831) 443-3058
Information & Assistance Unit (661) 395-2514
EUREKA, 95501-0529 * Satellite office *
SAN BERNARDINO, 92401-1411
409 “K” Street, Room 201
464 W Fourth Street, Suite 239
Information & Assistance Unit (707) 441-5723
Information & Assistance Unit (909) 383-4522
FRESNO, 93721-2219
SAN DIEGO, 92108-4424
2550 Mariposa Street, Suite 4078
7575 Metropolitan Drive, Suite 202
Information & Assistance Unit (559) 445-5355
Information & Assistance Unit (619) 767-2082
LONG BEACH, 90802-4339
SAN FRANCISCO, 94102-7014
nd
300 Oceangate Street, Suite 200
455 Golden Gate Avenue, 2
Floor
Information & Assistance Unit (562) 590-5240
Information & Assistance Unit (415) 703-5020
LOS ANGELES, 90013-1105
SAN JOSE, 95113-1402
th
th
100 Paseo de San Antonio, Suite 241
320 W 4
Street, 9
Floor
Information & Assistance Unit (408) 277-1292
Information & Assistance Unit (213) 576-7389
MARINA DEL REY, 90292-6902
SAN LUIS OBISPO, 93401-8736
nd
rd
4740 Allene Way, Suite 100
4720 Lincoln Boulevard, 2
and 3
floors
Information & Assistance Unit (805) 596-4159
Information & Assistance Unit (310) 482-3820
OAKLAND, 94612-1499
SANTA ANA, 92707-7704
th
2 MacArthur Place, Suite 600
1515 Clay Street, 6
Floor
Information & Assistance Unit (714) 942-7576
Information & Assistance Unit (510) 622-2861
OXNARD, 93030-7912
SANTA BARBARA, 93101-7538 * Satellite office *
1901 N Rice Avenue, Suite 100
130 E Ortega Street
Information & Assistance Unit (805) 485-3528
Information & Assistance Unit (805) 568-1390
POMONA, 91768-1653
SANTA ROSA, 95404-4771
732 Corporate Center Drive
50 “D” Street, Suite 420
Information & Assistance Unit (909) 623-8568
Information & Assistance Unit (707) 576-2452
REDDING, 96002-0940
STOCKTON, 95202-2314
nd
31 E Channel Street, Suite 344
250 Hemsted Drive, 2
Fl, Ste. B
Information & Assistance Unit (209) 948-7980
Information & Assistance Unit (530) 225-2047
RIVERSIDE, 92501-3337
VAN NUYS, 91401-3370
3737 Main Street, Suite 300
6150 Van Nuys Boulevard, Suite 105
Information & Assistance Unit (951) 782-4347
Information & Assistance Unit (818) 901-5374
Rev. 11/19
STATE OF CALIFORNIA
SAMPLE
DWC DISTRICT OFFICE
DOCUMENT COVER SHEET
 
 
 
 
 
 
 
 
Is this a new case?
Companion Cases Exist
Yes
No
Walkthrough
Yes
No
More than 15 Companion Cases
YOUR SOCIAL
TODAY'S DATE
SECURITY NUMBER
SSN:
Date:(MM/DD/YYYY)
Specific Injury
EAMS CASE NUMBER
DATE OF INJURY
Case Number 1
Cumulative Injury
(Start Date: MM/DD/YYYY)
(End Date: MM/DD/YYYY)
(If Specific Injury, use the start date as the specific date of injury)
IF NEW CASE
LEAVE BLANK
USE CODE FROM
Body Part 1:
BODY PART CODE
Body Part 3:
LIST, SEE PAGE 8
Body Part 2:
Body Part 4:
WHEN MORE THAN 5 BODY PARTS USE BODY
Other Body Parts:
PART NUMBER 700 IN THIS FIELD
Please check unit to be filed on ( check only one box )
ADJ
DEU
SIF
UEF
SAU
INT
RSU
Companion Cases
Specific Injury
Case Number 2
Cumulative Injury
(Start Date: MM/DD/YYYY)
)
(End Date: MM/DD/YYYY
(If Specific Injury, use the start date as the specific date of injury)
Body Part 1:
Body Part 3:
Body Part 2:
Body Part 4:
Other Body Parts:
DWC-CA form 10232.1 Rev. 11/2017- Page 1 of 8
 
 
District office codes for place of venue
Legend
 
Abbreviation
Office
AHM
Anaheim
ANA
Santa Ana
BAK
Bakersfield
EUR
Eureka*
FRE
Fresno
LAO
Los Angeles
LBO
Long Beach
MDR
Marina del Rey
OAK
Oakland
OXN
Oxnard
POM
Pomona
RDG
Redding
RIV
Riverside
SAC
Sacramento
SAL
Salinas
SBA
Santa Barbara**
SBR
San Bernardino
SDO
San Diego
SFO
San Francisco
SJO
San Jose
San Luis Obispo
SLO
SRO
Santa Rosa
STK
Stockton
VNO
Van Nuys
* Eureka is a satellite office of Santa Rosa district office. ** Santa Barbara is a satellite office of the Oxnard district office.
Use this document to complete forms, but do not file this document with your forms.
 
DWC-CA form 10232.1 Rev. 11/2017- Page 7 of 8
 
Body Part Code List
The body part codes listed below are used to complete forms that require the listing of
the part of the body that is in issue. Please do not file this document with your forms.
100
Head - not specified
500
Lower extremities - not specified
110
Brain
510
Legs - above ankles, not specified
120
Ear - not specified
511
Thigh femur
121
Ear - external
513
Knee Patella
124
Ear - internal including hearing
515
Lower leg tibia and fibula
130
Eye - including optic nerves and vision
518
Leg - multiple parts any combination of above parts
140
Face - not specified
519
Leg - not specified
141
Jaw - including chin and mandible
520
Ankle malleolus
144
Mouth - including lips, tongue, throat and taste
530
Foot not ankle or toe
145
Teeth
540
Toes
146
Nose - including nasal passages, sinus and smell
598
Lower extremities - multiple parts any combination of above parts
Multiple parts more than five major parts use only in fifth position
148
Face - multiple parts any combination of above parts
700
of listing of body parts
149
Face - forehead, cheeks, eyelids
800
Body system - not specific
Circulatory system - heart -other than heart attack, blood, arteries,
150
Scalp
801
veins, etc.
160
Skull
802
Circulatory system - Heart attack
198
Head - multiple injury any combination of above parts
810
Digestive system - stomach
200
Neck
820
Excretory system - kidneys, bladder, intestines, etc
300
Upper extremities - not specified
830
Musculo-skeletal system - bones, joints, tendons, muscles, etc.
310
Arm - above wrist not specified
840
Nervous system - not specified
311
Arm - upper arm humerus
841
Nervous system - stress
313
Arm - elbow head of radius
842
Nervous system - Psychiatric/psych
315
Arm -forearm radius and ulna
850
Respiratory system - lungs, trachea, etc.
318
Arm - multiple parts any combination of above parts
860
Skin dermatitis, etc.
319
Arm - not specified
870
Reproductive systems
320
Wrist
880
Other body systems
330
Hand - not wrist or fingers
999
Unclassified - insufficient information to identify body parts
340
Fingers
 
 
 
 
398
Upper extremities - multiple parts any combination of above parts
 
 
400
Trunk - not specified
 
 
410
Abdomen - including internal organs and groin
 
 
411
Hernia
 
 
420
Back - including back muscles, spine and spinal cord
 
 
430
Chest - including ribs, breast bone and internal organs of the chest
 
 
440
Hips - including pelvis, pelvic organs, tailbone, coccyx and buttocks
 
 
450
Shoulders - scapula and clavicle
 
 
498
Trunk - use for side; multiple parts any combination of above parts
Use this document to complete forms, but do not file this document with your forms.
DWC-CA form 10232.1 Rev. 11/2017- Page 8 of 8