What this form is for
Application for adjudication of claim *
Official file
Published by the Division of Workers' Compensation. This page does not replace the form — it points at the state's PDF and, where the form is what a panel actually ruled on, quotes that ruling.
How to fill a DWC form →Source: dir.ca.gov/dwc/forms.html. Unofficial guide — the PDF on that site is the form.
What the Appeals Board did with this
Decisions of the Workers' Compensation Appeals Board that turned on this kind of filing. Each quotes the passage it turned on and links to the official PDF.
- ADJ11687715 · 2026-09-24 · Sacramento District OfficeAOE/COEapplicant prevailed
Determinative passage · p.4The Court held that the uncontroverted evidence established exposure to smoke, the doctor stated that it was probable that the smoke inhaled contained carcinogens and it was reason that prolonged exposure could lead to lung cancer, need only establish that it was reasonably probable and was not required to produce exact type/amount of exposure, and that employment need only be a contributing cause. In the present matter, the issue of AOE/COE was addressed in the Findings of Fact. Applicant alleged that the decedent’s lung cancer and resulting death were caused by diesel exhaust exposure at work. The parties used Stuart Lonky, MD as the panel qualified medical evaluator. QME Lonky provided five reports and sat for four depositions. He reviewed extensive medical records, deposition transcripts from various employees at the City of Sacramento, including the Kristal the applicant, the injured worker’s spouse, and multiple medical articles on the relationship between diesel fumes and lung cancer. Throughout the reporting and deposition testimony, QME Lonky opined that there was industrial causation. QME Lonky’s
The Appeals Board agreed with the WCJ that the expert opinion of PQME Dr. Lonky constituted substantial medical evidence that the decedent's lung cancer and death were industrially caused by diesel exhaust exposure as a co-carcinogen, even with the decedent's smoking history, meeting the burden of proof by reasonable probability.
Official decision · page 4 → - ADJ7316783 · 2026-09-24 · Goleta District OfficeAOE/COEapplicant prevailed
Determinative passage · p.181. the applicant, while employed during the period of January 1, 2005 through October 31, 2009 as an office manager, occupational group number 214, at Santa Barbara, California by Ehlen, Spiess & Haight, Inc., sustained injury arising out of and in the course of employment to her left shoulder, neck, psyche and TMJ, right shoulder, and teeth. The issue of whether applicant sustained injury in the form of memory loss and headaches is deferred.
The Board found substantial evidence supporting industrial injury to these body parts and affirmed the WCJ's finding of injury.
Official decision · page 18 → - ADJ16035139 · 2026-09-21 · Bakersfield District OfficeAOE/COEapplicant prevailed
Determinative passage · p.1Defendant seeks reconsideration of the Rulings and Orders Admitting Evidence, Findings of Fact and Order (FF&O) issued by the presiding workers’ compensation administrative law judge (PWCJ) on April 30, 2026, wherein it was found that decedent sustained an injury arising out of and in the course of his employment (AOE/COE) in the form of cardiac arrest resulting in his death on March 31, 2022, while employed by defendant as farm worker. Defendant contends that the finding of AOE/COE was not based on substantial medical evidence. 10F
The substantial medical evidence from PQME Dr. Simon, who opined with reasonable medical probability that the decedent's physical labor activities contributed to his cardiac arrest and death, was unrebutted and supported the finding of injury AOE/COE. Defendant's argument for medical certainty was rejected as the law requires only reasonable medical probability for causation.
Official decision · page 1 → - ADJ21161039 · 2026-09-04 · Santa Ana District OfficeAOE/COEapplicant prevailed
Determinative passage · p.4The medical opinions of Dr. Nikakhtar constitutes substantial medical evidence of injury AOE/COE and were unrefuted. The WCJ provided the following analysis in the Opinion on Decision (OOD): A defendant will not be liable for medical treatment where there is no industrial injury. (Kunz v. Patterson Floor Coverings (2002) 67 Cal.Comp.Cases 1588, 1593 (Appeals Board en banc).) Where a lien claimant litigates the issue of entitlement to payment for industrially related medical treatment, the lien claimant stands in the shoes of the injured worker and the lien claimant must establish industrial injury by a preponderance of evidence. (Kaiser Foundation Hospitals v. Workers' Comp. Appeals Bd. (Martin) (1985) Cal.3d 57, 67 [50 Cal.Comp.Cases 411]; Kunz, supra, 67 Cal.Comp.Cases at p. 1592.)”
The WCJ found substantial medical evidence of injury AOE/COE based on Dr. Nikakhtar's medical opinion, which was unrefuted and based on reasonable medical probability after an adequate examination and evaluation. Defendant failed to provide evidence to refute the medical history or opinion. The WCAB affirmed the WCJ's findings and admitted lien claimants' exhibits into evidence.
Official decision · page 4 →