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Supplemental Job Displacement Nontransferable Training Voucher Form (Form
DWC-AD 10133.57 - Mandatory Form) For injuries occurring on or after 1/1/04
You have been determined eligible for this nontransferable, Supplemental Job Displacement Voucher. This voucher may be used for the payment of tuition, fees, books, and other expenses required by a state approved or accredited school that you enroll in for the purpose of education related retraining or skill enhancement, or both.
The state approved or accredited school will be reimbursed upon receipt of a documented invoice for tuition, fees, books and other required expenses required by the school for retraining or skill enhancement. If you pay for the eligible expenses, you may be reimbursed for these expenses upon submission of documented receipts. No more than 10 percent of the value of this voucher may be used for vocational or return to work counseling. If you decide to voluntarily withdraw from a program, you may not be entitled to a full refund of the voucher amount utilized.
Please present this original letter to the state approved or accredited school and/or the Vocational & Return to Work Counselor of your choice, chosen from the list developed by the Division of Workers' Compensation's Administrative Director, in order to initiate your training and return to work counseling. A list of Vocational & Return to Work Counselors is available on the Division of Workers' Compensation's website www.dir.ca.gov or upon request. The school and/or counselor should contact me regarding direct payment from your supplemental job displacement benefit.
Injured Employee Information: Upon completing the voucher form the injured employee must return the form with receipts and documentation to the claims administrator immediately for reimbursement. (The claims administrator must complete Nos. 1-8 of this voucher form prior to sending it to the injured employee.)
1. Injured Employee Name __________
2. Address __________ __________ __________ __________ __________ City __________State __________ Zip Code __________
3. Claim Number __________Phone Number __________
Claims Administrator
4. Name __________
5. Claims Mailing Address __________
6. City __________State __________ __________Zip Code __________
7. Claims Representative __________Phone Number __________ __________
8. $ __________ is available to the injured employee based on _____% of Permanent Partial Disability Award
The injured employee must complete Nos. 9-19 and sign and date this voucher form.
(VRTWC) Vocational Return to Work Counselor (if any)
9. Name __________Phone Number __________ __________
10. Address __________
11. City __________State __________ __________ Zip Code __________
12. Funds used for vocational and return to work counseling $________ (10% maximum of voucher value)
Training Provider Details (Attach additional pages for each provider if necessary.)
13. Provider Name __________
14. Provider Address __________Phone Number __________ __________
15. City __________State __________ __________ Zip Code __________
16. Provider approval number __________
17. Expiration Date ___________________
18. Provider Contact Name __________
19. Training Cost _________________
Injured Employee Signature __________Date __________
Note to Claims Administrator: Upon receipt of voucher, receipts and documentation from the employee, reimbursement payments to the employee or direct payments to VRTWC and training providers must be made within 45 calendar days.
Note: Authority cited: Sections 133, 4658.5 and 5307.3, Labor Code. Reference: Section 4658.5, Labor Code.
HISTORY
1. New section filed 6-6-2005; operative 8-1-2005 (Register 2005, No. 23). 8
CA ADC s 10133.57
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| The above information is provided free of charge by the Department of Industrial Relations from its web site at www.dir.ca.gov. |