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.

ADR Forms

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 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 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

Who do I contact if I have questions about the ADR Program?

The ADR program leaves the State’s substantive workers’ compensation law in place, but replaces the dispute resolution law with its own. When disputes arise that cannot be resolved by the ombudsman, a grievance may be filed and an informal conciliation session will promptly be set before a mediator. If the matter cannot be resolved at the informal conciliation, the matter will be set before an arbitrator who will hear the case and render a decision within 30 days. Either party may appeal the arbitrator’s decision to the Workers’ Compensation Appeals Board in San Francisco.

Employers or Insurance Agents

Employers or Insurance Agents who have questions about the ADR Program should call 916-869-6868, for Executive Director - Rick Pires

Injured Employees

Employees who qualify for the program and have been injured on the job should call 510-568-5920, for Ombudsman - Arthur Scears

Habla Espanol

Si usted habla espanol y usted califica para el progama y se ha lastimado en el trabajo debe llamar a Teresa Alvarado al numero 510-568-5920.