Petition To Terminate Liability For Temporary Disability Indemnity {WCAB 46}

STATE OF CALIFORNIA DIVISION OF WORKERS' COMPENSATION WORKERS' COMPENSATION APPEALS BOARD PETITION TO TERMINATE LIABILITY FOR TEMPORARY DISABILITY INDEMNITY DWC/WCAB FORM 46 (Page 1) (REV 11/2008) Injured Worker (Completion of this section is required) Employer InformationInsurance Carrier Information (if applicable - include even if carrier is adjusted by claims administrator)WCAB46 Zip Code City Insurance Carrier Street Address/PO Box (Please leave blank spaces between numbers, names or words) Insurance Carrier Name (Please leave blank spaces between numbers, names or words) Zip Code City Employer Street Address/PO Box (Please leave blank spaces between numbers, names or words) Employer Name (Please leave blank spaces between numbers, names or words) Insured Self-Insured Legally Uninsured Uninsured MI Last Name First Name Case Number 5 Case Number 4 Case Number 3 Case Number 2 Case Number 1 State State DWC/WCAB FORM 46 (Page 2) (REV 11/2008) thatfor the period NOTE: Section 10466 of title 8 of the California Code of Regulations provides as follows: "IF WRITTEN OBJECTION IS NOT RECEIVED TO THE PETITION WITHIN FOURTEEN DAYS OF ITS PROPER FILING AND SERVICE, THE WCAB MAY ORDER TEMPORARY DISABILITY COMPENSATION TERMINATED, in accordance with the facts as stated in the petition or in such other manner as may appear appropriate on the record." Defendants are informed and believe that applicantAdvancesper week and will continue until.Defendants request that the Workers' Compensation Appeals Board make an order terminating liability for temporary disability indemnity unless the employee objects, and if the employee does object, that this petition be set for hearing. All medical reports in petitioner's possession not previously served and filed herein, are attached hereto, served herewith.By Claims Administrator Information (if applicable)WCAB46 Zip Code State City Street Address/PO Box (Please leave blank spaces between numbers, names or words) Name (Please leave blank spaces between numbers, names or words) DEFENDANTS ALLEGE that temporary disability was heretofore found by a WCAB decision of temporary disability has been paid in the total sum of $ to that temporary disability terminated on Dated (3) Applicant's condition is permanent and stationary as shown by the attached medical report(s). (4) Applicant's condition has reached maximum medical improvement as shown by the attached medical report(s). (5) Other (2) Applicant was declared able to return to work on said date per report of Dr. (1) Applicant returned to work on said date. is presently working is not presently working are are not being made on permanent disability indemnity at the rate of $ approximately ( Insurer / Employer ) I declare under penalty of perjury that the allegations contained in this petition are true and correct to the best of my knowledge and belief.