Instructions for completing the Request for Dispute Resolution Before Administrative Director

Español

If you disagree with the claims administrator about the SJDB voucher, you can file a Request for Dispute Resolution form with the DWC. The form will be reviewed by the DWC and a decision will be issued. Send the "Request for Dispute Resolution" form to:

State of California
Department of Industrial Relations 
Division of Workers' Compensation
Attention: SJDB
P.O. Box 42060
San Francisco, CA 94142

REQUIRED CHECKLIST FOR FILING THIS FORM
Please file the forms in the order indicated Samples

Instrucciones para completar la Solicitud de Resolución de Disputas Antes del Director Administrativo

English

Si no está de acuerdo con el administrador de reclamos sobre el vale de SJDB, usted puede presentar un formulario de Solicitud de Resolución de Disputas con la DWC. El formulario será revisado por la DWC y se emitirá una decisión.  Envíe el formulario "Solicitud de Resolución de Disputas" a:

State of California
Department of Industrial Relations 
Division of Workers' Compensation
Attention: SJDB
P.O. Box 420603
San Francisco, CA 94142

 

LISTA DE CONTROL OBLIGATORIA PARA PRESENTAR ESTE FORMULARIO
Por favor presente los formularios en el orden indicado Muestras

October 2017