Dispute Resolution System
The document packet provided to all employers and employees who are part of the ADR program can be downloaded below. All documents are PDFs and require Acrobat Reader to view.
- Acknowledgement Form
- Workers' Compensation Addendum
- Program Overview Documents
- Medical Provider Network
- Rules of Practice and Procedure
- Acknowledgement Form
- Workers' Compensation Addendum
- Program Overview Documents
- Medical Provider Network
- Rules of Practice and Procedure
ADR Forms
adr-compromise.release.order.vfields.pdfadr-compromise.release.order.vfields.pdfadr-compromise.release.order.pdf(All forms are now type-able)
- Form 100 – Information Provided to Interested Persons
Where information is requested from the Basic Crafts Workers’ Compensation Program, it may be provided to the interested person by attaching it to this form and sending it to the interested person.
- Form 102 – Notice of Ombudsman’s Final Response
Where the employee is not represented by counsel and the Ombudsman cannot resolve a dispute, a final response will be provided to the employee, and the employee will have the right to file a Workers’ Compensation Grievance within 30 days of the final response and seek an Informal Conciliation before a mediator.
- Form 103 – Workers’ Compensation Grievance
This document must be filed within 30 days of the issuance of the Notice of Ombudsman’s Final Response, in the case of an unrepresented injured worker, or within 30 days of the issuance of the carriers’ final response, in the case of a represented injured worker. This time limit may be extended by the ADR Director upon a showing of good cause. The filing of a Grievance will result in the setting of an informal conciliation with a mediator, forthwith.
- Form 104 - Workers’ Compensation Grievance – Death Case
This is essentially the same form as form 103, but applies to cases where the injury resulted in death.
- Form 105 – Director’s Notice of Informal Conciliation
Upon the filing of a Workers’ Compensation Grievance, the ADR Director may schedule an informal conciliation and issue this form as confirmation.
- Form 106 – Arbitration Request
Where the Informal Conciliation does not result in an agreement either party may file a Request to Arbitrate within 30 days of the Informal Conciliation.
- Form 107 – Declaration of Readiness to Arbitrate
When prepared to go forward, a Declaration of Readiness to Arbitrate shall be filed with the Basic Crafts ADR Director, and the ADR Director shall schedule the Arbitration proceeding as soon as possible, while allowing the parties time to prepare.
- Form 108 – Notice to Testify and Produce
This is the document used to subpoena both persons to testify and documents to be produced in a proceeding conducted under the jurisdiction of the Basic Crafts Workers’ Compensation Program.
- Form 110 – ADR Director’s Notice of Scheduled Arbitration
After a Request to Arbitrate has been timely filed, and when a party is prepared to go forward, a Declaration of Readiness to Arbitrate shall be filed with the Basic Crafts ADR Director, and the ADR Director shall schedule the Arbitration proceeding as soon as possible, while allowing the parties time to prepare.
- Form 200 – Compromise, Release and Order Approving
This is the document used to prepare a settlement agreement to resolve a claim or claims, usually on a lump sum basis in a manner that closes the claim entirely.
- Form 201 – Stipulations with Request for Award
This is the document used to prepare a settlement agreement to resolve a claim or claims on the basis of a series of stipulations regarding the issues in dispute. This approach to resolution most closely resembles the effect of an arbitrators Findings and Award.
- Form 202 – Stipulation and Award and/or Order
This document is used to prepare a settlement agreement to resolve a claim or claims regarding the issues in dispute. The parties waive the provisions of Labor Code §5313 and then specify the stipulations being made.
- Form 300 – Lien Claim
NOTICE AND REQUEST FOR ALLOWANCE OF LIEN
- Form 100 – Information Provided to Interested Persons
Where information is requested from the Basic Crafts Workers’ Compensation Program, it may be provided to the interested person by attaching it to this form and sending it to the interested person.
- Form 102 – Notice of Ombudsman’s Final Response
Where the employee is not represented by counsel and the Ombudsman cannot resolve a dispute, a final response will be provided to the employee, and the employee will have the right to file a Workers’ Compensation Grievance within 30 days of the final response and seek an Informal Conciliation before a mediator.
- Form 103 – Workers’ Compensation Grievance
This document must be filed within 30 days of the issuance of the Notice of Ombudsman’s Final Response, in the case of an unrepresented injured worker, or within 30 days of the issuance of the carriers’ final response, in the case of a represented injured worker. This time limit may be extended by the ADR Director upon a showing of good cause. The filing of a Grievance will result in the setting of an informal conciliation with a mediator, forthwith.
- Form 104 - Workers’ Compensation Grievance – Death Case
This is essentially the same form as form 103, but applies to cases where the injury resulted in death.
- Form 105 – Director’s Notice of Informal Conciliation
Upon the filing of a Workers’ Compensation Grievance, the ADR Director may schedule an informal conciliation and issue this form as confirmation.
- Form 106 – Arbitration Request
Where the Informal Conciliation does not result in an agreement either party may file a Request to Arbitrate within 30 days of the Informal Conciliation.
- Form 107 – Declaration of Readiness to Arbitrate
When prepared to go forward, a Declaration of Readiness to Arbitrate shall be filed with the Basic Crafts ADR Director, and the ADR Director shall schedule the Arbitration proceeding as soon as possible, while allowing the parties time to prepare.
- Form 108 – Notice to Testify and Produce
This is the document used to subpoena both persons to testify and documents to be produced in a proceeding conducted under the jurisdiction of the Basic Crafts Workers’ Compensation Program.
- Form 110 – ADR Director’s Notice of Scheduled Arbitration
After a Request to Arbitrate has been timely filed, and when a party is prepared to go forward, a Declaration of Readiness to Arbitrate shall be filed with the Basic Crafts ADR Director, and the ADR Director shall schedule the Arbitration proceeding as soon as possible, while allowing the parties time to prepare.
- Form 200 – Compromise, Release and Order Approving
This is the document used to prepare a settlement agreement to resolve a claim or claims, usually on a lump sum basis in a manner that closes the claim entirely.
- Form 201 – Stipulations with Request for Award
This is the document used to prepare a settlement agreement to resolve a claim or claims on the basis of a series of stipulations regarding the issues in dispute. This approach to resolution most closely resembles the effect of an arbitrators Findings and Award.
- Form 202 – Stipulation and Award and/or Order
This document is used to prepare a settlement agreement to resolve a claim or claims regarding the issues in dispute. The parties waive the provisions of Labor Code §5313 and then specify the stipulations being made.
- Form 300 – Lien Claim
NOTICE AND REQUEST FOR ALLOWANCE OF LIEN