Form I&A5 "Information & Assistance Unit Guide - How to File a Declaration of Readiness to Proceed" - California

What Is Form I&A5?

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 June 1, 2018;
  • 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&A5 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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Download Form I&A5 "Information & Assistance Unit Guide - How to File a Declaration of Readiness to Proceed" - California

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Information & Assistance Unit guide 5
How to file a declaration of readiness to proceed
File a declaration of readiness to proceed (DOR) to request a conference at your
local Workers’ Compensation Appeals Board (WCAB) office.
A conference will be set only if you filed an application for adjudication of claim
and a WCAB case number has been set up. If you don’t have a WCAB case
number, you will also need to file an application for adjudication of claim, which
opens a WCAB case for you (see I&A guide 4).
Complete the form following the attached sample. Provide the specific information
requested about how you tried to resolve the issues. This form can also be
completed at
http://www.dir.ca.gov/dwc/FORMS/EAMS%20Forms/ADJ/DWCCAForm10250_1.pdf
When you file the DOR, you should also file all relevant medical reports and
records, and all letters from the insurance company about the issues in dispute.
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
(for Declaration of Readiness to Proceed)
Document Separator Sheet
Declaration of Readiness To Proceed
(for Proof of Service By Mail)
Document Separator Sheet
Proof of Service By Mail
Keep copies of your filings for your records.
The WCAB will review the DOR. All parties will be notified by mail when a
conference is set.
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.
I&A 5
Rev. 06/18
Information & Assistance Unit guide 5
How to file a declaration of readiness to proceed
File a declaration of readiness to proceed (DOR) to request a conference at your
local Workers’ Compensation Appeals Board (WCAB) office.
A conference will be set only if you filed an application for adjudication of claim
and a WCAB case number has been set up. If you don’t have a WCAB case
number, you will also need to file an application for adjudication of claim, which
opens a WCAB case for you (see I&A guide 4).
Complete the form following the attached sample. Provide the specific information
requested about how you tried to resolve the issues. This form can also be
completed at
http://www.dir.ca.gov/dwc/FORMS/EAMS%20Forms/ADJ/DWCCAForm10250_1.pdf
When you file the DOR, you should also file all relevant medical reports and
records, and all letters from the insurance company about the issues in dispute.
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
(for Declaration of Readiness to Proceed)
Document Separator Sheet
Declaration of Readiness To Proceed
(for Proof of Service By Mail)
Document Separator Sheet
Proof of Service By Mail
Keep copies of your filings for your records.
The WCAB will review the DOR. All parties will be notified by mail when a
conference is set.
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.
I&A 5
Rev. 06/18
Information & Assistance Unit guide 5
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 5
Rev. 06/18
 
 
 
 
 
 
 
 
 
 
 
 
 
WORKERS’ COMPENSATION APPEALS BOARD DISTRICT OFFICES
ANAHEIM, 92806-2131
SACRAMENTO, 95834-2962
1065 North 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 * Virtual office *
SAN BERNARDINO, 92401-1411
Information & Assistance Unit
464 W Fourth Street, Suite 239
Information & Assistance Unit (909) 383-4522
(707) 441-5723
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, 90810-1870
SAN FRANCISCO, 94102-7014
1500 Hughes Way, Suite C203
nd
455 Golden Gate Avenue, 2
Floor
Information & Assistance Unit (424) 450-2565
Information & Assistance Unit (415) 703-5020
LOS ANGELES, 90013-1105
SAN JOSE, 95113-1402
100 Paseo de San Antonio, Suite 241
th
th
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
Floor, Suite 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. 07/21
STATE OF CALIFORNIA
DWC DISTRICT OFFICE
+
+
DOCUMENT COVER SHEET
Is this a new case?
Yes
D
NoD
Companion Cases Exist
D
Walkthrough
Yes
D
No
D
More than 15 Companion Cases
D
SSN:
Date:(MM/DD/YYYY)
D
Specific Injury
Case Number 1
D
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:
Please check unit to be filed on ( check only one box )
D
ADJ
D
DEU
D
SIF
D
UEF
D
SAU
DINT
0RSU
Companion Cases
Case Number 2
D
Specific Injury
D
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:
I
DWC-CA form 10232.1 Rev. 5/2020- Page 1 of 8
+
SAMPLE
YOUR SOCIAL
TODAY'S DATE
SECURITY NUMBER
DATE OF INJURY
EAMS CASE NUMBER
IF NEW CASE
LEAVE BLANK
USE CODE FROM
BODY PART CODE LIST --
SEE PAGE 8
WHEN MORE THAN 5 BODY PARTS USE BODY
PART NUMBER 700 IN THIS FIELD
 
 
 
 
   
       
 
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
SLO
San Luis Obispo
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 Oxnard district office.
Use this document to complete forms,
but do not file this document with your forms.
DWC‐CA form 10232.1 Rev. 5/2020 – Page 7 of 8
Page of 13