Workers' Compensation Employer Response

EMPLOYER'S RESPONSE TO WORKERS' COMPENSATION CLAIM

(Answer to Application for Adjudication / Response to Claim)

PART 1: CASE IDENTIFICATION

WCAB/Board Case Number: [NUMBER]

Claim Number: [NUMBER]

Date of Response: [DATE]

Response to:
☐ Application for Adjudication of Claim dated [DATE]
☐ Employee Claim Form dated [DATE]
☐ Amended Application dated [DATE]
☐ Other: [SPECIFY]

PART 2: PARTIES

2.1 Applicant (Injured Worker)

Name: [FULL NAME]

Date of Birth: [DATE]

Alleged Date of Injury: [DATE]

Alleged Body Parts: [LIST]

Applicant's Attorney (if any):
Name: [NAME]
Firm: [FIRM]
Address: [ADDRESS]
Phone: [PHONE]

2.2 Employer (Defendant)

Employer Name: [LEGAL NAME]

Address:
[STREET ADDRESS]
[CITY], [STATE] [ZIP CODE]

Phone: [PHONE]

2.3 Insurance Carrier

Carrier Name: [NAME]

Policy Number: [NUMBER]

Claim Number: [NUMBER]

Claims Examiner: [NAME]

Address:
[STREET ADDRESS]
[CITY], [STATE] [ZIP CODE]

Phone: [PHONE]

2.4 Defense Attorney

Attorney Name: [NAME]

State Bar Number: [NUMBER]

Firm Name: [FIRM]

Address:
[STREET ADDRESS]
[CITY], [STATE] [ZIP CODE]

Phone: [PHONE]

Fax: [FAX]

Email: [EMAIL]

PART 3: RESPONSE TO ALLEGATIONS

3.1 Employment Status

Allegation: Applicant was employed by Defendant.

Response:
☐ Admit
☐ Deny
☐ Deny for Lack of Information
☐ Admit in Part: [EXPLAIN]

If Denied, Explain:
____________________________________________________________________________

3.2 Employment Relationship at Time of Injury

Allegation: At the time of the alleged injury, Applicant was employed by Defendant.

Response:
☐ Admit
☐ Deny (Applicant was ☐ terminated ☐ resigned ☐ never employed)
☐ Deny for Lack of Information
☐ Admit in Part: [EXPLAIN]

Dates of Employment: [START DATE] to [END DATE]

3.3 Date of Injury

Alleged Date of Injury: [DATE]

Response:
☐ Admit
☐ Deny - Correct date is: [DATE]
☐ Deny - No injury occurred
☐ Deny for Lack of Information

3.4 Body Parts

Alleged Body Parts: [LIST]

Response:
☐ Admit all body parts
☐ Deny all body parts
☐ Admit in Part:
Admitted: [LIST ADMITTED BODY PARTS]
Denied: [LIST DENIED BODY PARTS]
☐ Deny for Lack of Information

3.5 Injury Arising Out of Employment (AOE)

Allegation: The injury arose out of employment.

Response:
☐ Admit
☐ Deny
☐ Deny for Lack of Information

If Denied, Explain:
____________________________________________________________________________

3.6 Injury in Course of Employment (COE)

Allegation: The injury occurred in the course of employment.

Response:
☐ Admit
☐ Deny
☐ Deny for Lack of Information

If Denied, Explain:
____________________________________________________________________________

3.7 Notice of Injury

Allegation: Applicant provided timely notice of injury to Employer.

Response:
☐ Admit
☐ Deny - Notice was untimely (received on [DATE])
☐ Deny - No notice was received
☐ Deny for Lack of Information

3.8 Statute of Limitations

Was the claim filed within the applicable statute of limitations?

☐ Admit - Claim was timely filed
☐ Deny - Claim is barred by statute of limitations
☐ Reserve - Statute of limitations defense is reserved pending investigation

PART 4: AFFIRMATIVE DEFENSES

4.1 Asserted Defenses

Defendant asserts the following affirmative defenses:

☐ Statute of Limitations
The claim is barred by the applicable statute of limitations.
Applicable deadline: [DATE]
Claim filed: [DATE]

☐ Lack of Notice
Applicant failed to provide notice of injury within the time required by law.

☐ Non-Industrial Injury
The alleged injury did not arise out of or in the course of employment.
Explanation:
____________________________________________________________________________

☐ Pre-Existing Condition
Applicant's condition existed prior to employment and was not caused or aggravated by employment.
Explanation:
____________________________________________________________________________

☐ Willful Misconduct
The injury was caused by Applicant's willful misconduct.
Explanation:
____________________________________________________________________________

☐ Intoxication
The injury was caused by Applicant's intoxication by alcohol or drugs.
Explanation:
____________________________________________________________________________

☐ Self-Inflicted Injury
The injury was intentionally self-inflicted.
Explanation:
____________________________________________________________________________

☐ Horseplay
The injury occurred during horseplay or activities outside the scope of employment.
Explanation:
____________________________________________________________________________

☐ Violation of Safety Rules
The injury resulted from Applicant's willful violation of known safety rules.
Explanation:
____________________________________________________________________________

☐ Going and Coming Rule
The injury occurred while going to or coming from work.
Explanation:
____________________________________________________________________________

☐ Independent Contractor
Applicant was an independent contractor, not an employee.
Explanation:
____________________________________________________________________________

☐ Fraud
There is evidence of fraud in connection with this claim.
Explanation:
____________________________________________________________________________

☐ Apportionment
Defendant is entitled to apportionment of disability to:
☐ Prior industrial injury
☐ Pre-existing non-industrial condition
☐ Subsequent injury
☐ Natural progression of disease
Explanation:
____________________________________________________________________________

☐ Third-Party Liability / Credit
A third party was responsible for the injury. Defendant reserves subrogation rights and credit.
Third Party: [NAME]
Explanation:
____________________________________________________________________________

☐ Other Defense:
[DESCRIBE]
____________________________________________________________________________

4.2 Reservation of Defenses

Defendant reserves the right to assert additional defenses as investigation continues.

PART 5: CLAIM STATUS AND BENEFITS

5.1 Claim Acceptance Status

Current Claim Status:

☐ Claim Accepted
Body parts accepted: [LIST]
Date accepted: [DATE]

☐ Claim Denied
Date of denial: [DATE]
Reason(s): [EXPLAIN]

☐ Claim Partially Accepted
Body parts accepted: [LIST]
Body parts denied: [LIST]
Reason for partial denial:
____________________________________________________________________________

☐ Under Investigation
Expected completion date: [DATE]

5.2 Benefits Provided

Benefits Paid to Date:

5.3 Benefits Contested

Defendant disputes the following requested benefits:

☐ Temporary disability for period: [DATES]
Reason:
____________________________________________________________________________

☐ Permanent disability rating of: [%]
Defendant's position:
____________________________________________________________________________

☐ Medical treatment: [DESCRIBE]
Reason:
____________________________________________________________________________

☐ Future medical treatment
Reason:
____________________________________________________________________________

☐ Other: [SPECIFY]
____________________________________________________________________________

PART 6: MEDICAL EVIDENCE

6.1 Medical Evaluation Status

QME/AME Status:

☐ AME agreed upon: [PHYSICIAN NAME]
☐ QME panel obtained, selection made: [PHYSICIAN NAME]
☐ QME panel obtained, selection pending
☐ QME evaluation completed on [DATE]
☐ QME report received on [DATE]
☐ No QME/AME yet

6.2 Medical Reports

Medical Reports in Defendant's Possession:

PART 7: EMPLOYMENT AND WAGE INFORMATION

7.1 Employment Details

Job Title: [TITLE]

Date of Hire: [DATE]

Date of Termination (if applicable): [DATE]

Reason for Termination: [REASON]

Employment Status at Time of Injury:
☐ Full-Time ☐ Part-Time ☐ Seasonal ☐ Temporary

7.2 Wage Information

Average Weekly Wage: $[AMOUNT]

Basis for Wage Calculation:
☐ 52-week average
☐ Actual wages for period worked
☐ Similar employee wages
☐ Other: [SPECIFY]

Temporary Disability Rate: $[AMOUNT]

Permanent Disability Rate: $[AMOUNT]

PART 8: DISCOVERY REQUESTS

8.1 Document Requests

Defendant requests the following documents from Applicant:

☐ All medical records related to the claimed body parts
☐ Records of prior injuries to the same body parts
☐ Prior workers' compensation claims
☐ Employment records from other employers
☐ Tax returns for [YEARS]
☐ Social Security records
☐ Other: [SPECIFY]

8.2 Deposition Notice

☐ Defendant intends to take Applicant's deposition
☐ Defendant intends to take depositions of:

• [NAME], [REASON]
• [NAME], [REASON]

PART 9: SETTLEMENT POSITION

9.1 Settlement Interest

☐ Defendant is willing to discuss settlement
☐ Case is not ready for settlement - further development needed
☐ Defendant's current settlement position: [DESCRIBE OR RESERVE]

9.2 Mandatory Settlement Conference

☐ Defendant is prepared for MSC
☐ Additional discovery needed before MSC
☐ QME report needed before MSC

PART 10: VERIFICATION AND SIGNATURE

10.1 Verification

I, [NAME], declare under penalty of perjury that:

☐ I am the attorney for Defendant and/or an authorized representative of the insurance carrier.

☐ The factual statements in this Response are true and correct to the best of my knowledge based on information available to me.

☐ The defenses asserted are made in good faith based on the information currently available.

☐ This Response is filed within the time required by applicable law.

10.2 Signature

Signature: _________________________________

Printed Name: [NAME]

Title: [TITLE]

State Bar Number (if attorney): [NUMBER]

Date: [DATE]

PART 11: PROOF OF SERVICE

I declare that on [DATE], I served a true copy of this Employer's Response on:

Signature: _________________________________

Date: [DATE]

PART 12: FILING INFORMATION

File this Response with:

Workers' Compensation Appeals Board/Commission:
[DISTRICT OFFICE]
[ADDRESS]
[CITY], [STATE] [ZIP]

Electronic Filing: [SYSTEM NAME/URL]

Filing Deadline: [DATE]

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