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California Form Center


Welcome to the most extensive library of workers' compensation forms available anywhere. Almost 3,000 forms are available for your immediate download and use. Our forms, all of which have been custom programmed by WorkersCompensation.com for Type & Save functionality, are available for individual purchase below.

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EAMS OCR forms - draft forms for voluntary use until EAMS regulations become effective are available on the California DWC website. These forms are not final and refinements are being made.
(DLSR-5020) Employer's Report of Occupational Injury or Illness - 6/02
(DLSR-5021) Doctor's First Report of Occupational Injury or Illness - 1992
(DIA-510) Notice of Employee Death - 9/84
(DWC-1) Workers' Compensation Claim form (Employee) - 11/08
(DWC-5) Request for Accommodations by Persons with Disabilities - 1/06
(DWC-6) Notice and Request For Allowance of Lien - 11/08
(DWC-46) Petition To Terminate Liability For Temporary Disability Indemnity - 11/08
(DWC-280) Petition for Change of Primary Treating Physician - 1/01
(mileage06) Medical mileage expense form in English/Spanish - for travel between 7/1/06 and 1/1/07
(mileage07) Medical mileage expense form in English/Spanish - for travel on or after 1/1/07
(mileage0708) Medical mileage expense form in English/Spanish - for travel on or after 7/1/08
(mileage08) Medical mileage expense form in English/Spanish - for travel on or after 1/1/08
(mileage09) Medical Mileage Expense Form - 1/09
(NoticePoster) Notice to Employees Poster (English and Spanish) - 8/04
(Seriousandwillful) Application For Benefits For Serious And Willful Misconduct Of Employer - N/D
(ADB-132a) Application For Discrimination Benefits Pursuant To Labor Code
COURT FORMS
(ArbitrationApplication) Arbitrator Application - 4/07
(DWC-WCAB-1) Application for Adjudication of Claim - N/D
(DWC-4) Declaration of Readines to Proceed - Expedited Hearing (Trial) - 1/03
(DWC-9) Declaration of Readiness to Proceed - 1/03
(DWC-10) Answer To Application For Adjudication Of Claim - 7/08
(Consultr) Request for Consultative Rating - 2/02
(CR15) Compromise and release - 10/05
(SAO5) Stipulation and award and/or order - 10/05
(pretrial) PreTrial Conference Statement - N/D
(SRA3) Stipulations with request for award - 10/05
(minotoc) Minutes of Hearing/Order/Order and Decision on Request for Continuance/ Order Taking Off
(DWC-49) Petition for Commutation of Future Payments - 11/74
(DWC-37) Notice of Dismissal of Attorney - 8/75
(DWC-45) Petition for Reconsidertion - 3/76
(DWC-6) Notice and Request for Allowance of Lien - 7/08
(DWC-8) Petition for Appointment of Guardian ad Litem and Trustee - 10/90
(DWC-42) Petition to Reopen - 8/85
(DWC-10214a) Stipulations With Request For Award - 11/08
(DWC-10214b) Stipulations With Request For Award (Death Case) - 11/08
(DWC-10214c) Compromise And Release - 11/08
(DWC 10214d) COMPROMISE AND RELEASE (Dependency claim) - 11/08
(DWC 10214e) Third Party Compromise And Release - 11/08
(DWC-CA-10232 1) Document Cover Sheet - 11/08
(DWC-10245) Minutes Of Hearing - 11/08
(setguide) Information Guidelines For Submission Of Settlement Documents - N/D
PHYSICIAN FORMS
(AFD) Appeal From Determination And Order Of The Rehabiliation Unit - N/D
(PR-2) Primary Treating Physican's Progress Report - 6/05
(PR-3) Primary Treating Physican's Permanent and Stationary Report - 6/05
(PR-4) Primary Treating Physician's Permanent and Stationary Report - 6/05
(DWC-9783 1) Notice Of Personal Chiropractor Or Personal Acupuncturist - 3/06
(DWC-9783 1 sp) Noticia De Quiropráctico Personal O Acupuntor Personal - 3/06
(DWC-9783) Predesignation Of Personal Physician - 3/07
(DWC-9783 sp) Designación Previa De Médico Particular - 3/07
(DWC-232) Application For Spinal Surgery 2nd Opinion Physician List - 5/07
(DWC-233) Objection To Treating Physician's Recommendation For Spinal Surgery - 5/07
Cover page for medical provider network - N/D
(MPN-notice) Notice of medical provider network plan modification
DISABILITY EVALUATION UNIT (DEU) FORMS
(DEU-100) Employee's Permanent Disability Questionnaire - 11/08
(DEU-101) Request for Summary Rating Determination (of AME's or QME's Report) - 11/08
(DEU-102) Request for Summary Rating Determination (of Primary Treating Physician's Report) - 11/08
(DEU-103) Request for Reconsideration of Summary Rating by the Administrataive Director - 11/08
(DEU-104) Request For Consultative Rating - 11/08
(DEU-105) Apportionment - 1/05
(DEU-110) Notice of Options Following Permanent Disability Rating - 1/05
(DEU-200) Employee's Request for Information Pemanent Disability Rating - 8/79
(DEU-201) Request for Informal Rating (by Insuarance Carrier or Self-Insurer) - 8/90
VOCATIONAL REHABILITATION FORMS
(RB-105) Request for Conclusion - 1/03
(RB-107) Declination for Date Of Injury's pre 1/1/90
(RU-90) Treating Physician Report of Disability - 12/90
(RU-91) Description of Job Duties - 1/95
(RU-94) Notice of Offer of Modified or Alternate Work - 1/03
(RU-102) Rehabilitation Plan - 11/08
(RU-103) Request for Dispute Resolution - 11/08
(RU-105) Notice of Termination - 11/08
(RU-107) Declination for Date Of Injury's 1-1-90 - 12-31-93 (12/02)
(RU-107A) Declination for Date Of Injury's (1/94)
(RU-120) Evaluation Summary - 1/03
(RU-121) Progress Report - 9/98
(RU-122) Settlement Prospective of Voc Rehab Services - 11/08
RETURN TO WORK FORMS
(DWC-AD-10003) Notice Of Offer Of Regular Work - 9/06
(DWC-AD-10003 sp) Noticia De Oferta De Trabajo Regular - 9/06
(DWC-AD-10005) Request for Reimbursement of Accommodation Expenses - 8/06
(DWC-AD-10118) Notice Of Offer Of Regular Work - 11/08
(DWC-AD-10120) Request for Reimbursement of Accommodation Expenses For injuries on or after July 1, 2004 - 11/08
(DWC-AD-10133.53) Notice Of Offer Of Modified Or Alternative Work - 11/08
(DWC-AD-10133.53 sp) Noticia De Oferta De Trabajo Modificado O Alternativo - 8/06
(DWC-AD-10133 55) Request For Dispute Resolution Before Administrative Director - 11/08
(DWC-AD-10133 57) Supplemental Job Displacement Nontransferable Training Voucher Form - 11/08
Document Separator Sheet - 8/08
(DWC-CA-10232 1) Document Cover Sheet - 11/08
Document Separator Sheet - 11/08
Document Separator Sheet - 11/08
(DWC-CA-10250 1) Declaration Of Readiness To Proceed - 11/08
(DWC-CA-10252 1) Declaration Of Readiness To Proceed To Expedited Hearing (Trial) - 11/08
(DWC-AD-10253 1) Pre-Trial Conference Statement - Notice of Hearing - 11/08
(DWC-CA-10297) Arbitration Submittal Form - 11/08
SELF INSURANCE FORMS
(SIP-A4-100) Application for Self Insurance Administrator's Examination - 12/97
(SIP-A4-1) Application for a Certificate of Consent to Self Insure - 2/92
(SIP-A4-2) Application for a Public Entity Certificate of Consent to Self Insure - 2/92
(SIP-A4-50) Application for a Certificate of Consent to Administer Workers' Compensation Self Insurance Claims - 8/96
(SIP-4-3) Application for a certificate of consent to self insure by a group of employers - 1/94
(SIP-A4-3M) Application For An Affiliate Certificate Of Consent - 1/94
(SIP-4-5) Application for a Permanent Certificate of Consent to Self Insure by an Interim Self Insurer - 11/97
(SIP-4-6) Agreement of Assumption and Guarantee of Workers' Compensation Liabilities - 11/97
(SIPCorpResolution) Corporate Resolution Authorizing Application - N/D
(GAI request) Request For Interim Certificate For Group Member - N/D
(SIPintcer) Request For Interim Certificate - N/D
(SIPinfo) Information Bulletin: Approved Securities - N/D
(SIPinfotrust) Information Bulletin: Cash in Trust - N/D
(SIPinfo1) Information Bulletin: Letter of Credit - N/D
(SIPinfo2) Information Bulletin: Surety Bond - 12/01
MISCELLANEOUS FORMS
(EDEX client) EDEX client acknowledgment - 6/06
(EDEX subscriber) EDEX Subscriber Application - 6/06
(EDEX clientlist) EDEX Client List - 6/06
(DWC-UR1) Utilization Review Complaint Form - 10/07
(DWC-AU-906) How to File a Complaint with the Audit Unit - 6/06
(DWC-AU-905) Audit Referral Form - 6/06
(Ethform) Complaint and Information - N/D
(DWC-RGS-1) Petition for Permission to Negotiate a Section 3201.7 Labor-Management Agreement - 1/04
(PublicRecordsRequest) Request for Public Records - 10/06
(DWC-SMBFR-1115) Report of Suspected Medical Care Provider Fraud - 3/06
(SIFApplication) Application For Subsequent Injuries Fund Benefit - 11/08
(UEF50) Application For Discretionary Payments From The Uninsured Employers' Fund - 11/08
(WCAB-DWC-10) Answer to Application for Adjudication of Claim - 11/08
QUALIFIED MEDICAL EVALUATOR (QME) AND AGREED MEDICAL EVALUATOR (AME) FORMS
(QMEForm100) Application For Appointment As Qualified Medical Evaluator - 2/09
(QMEForm102) Registration For Qme Competency Examination - 2/09
(QMEForm104) Reappointment Application As Qualified Medical Evaluator - 2/09
(QMEForm105) Medical Unit Request For Qme Panel Under Labor Code § 4062.1 Unrepresented - 2/09
(QMEForm105Spanish) División De Compensación De Trabajadores – Unidad Médica Solicitud Para Un Panel De Qme Bajo El Código Laboral § 4062.1 Sin Representación - 2/09
(QMEForm105Attachment) How To Request A Qualified Medical Evaluator If You Do Not Have An Attorney Instructions - 2/09
(QMEForm106) Medical Unit Request For Qme Panel Under Labor Code § 4062.2 Represented - 2/09
(QMEForm106Attachment) How To Request A Qualified Medical Evaluator In A Represented Case Instructions - 2/09
(QMEForm109) Qme Notice Of Unavailability (Form must be filed 30 days prior to date of unavailability) - 2/09
(QMEForm110) Qme Appointment Notification Form
(QMEForm111) Qualified Medical Evaluator\'s Findings Summary Form Unrepresented Injured Employee Cases Only 2/09
(QMEForm112) Qme/Ame Report Time Frame Extension Request - 2/09
(QMEForm118) Application For Accreditation Or Re-Accreditation As Education Provider - 2/09
(QMEForm118Attachent) Application For Accreditation as an Education Provider Instructions- 2/09
(QMEForm119) Faculty Disclosure Of Commercial Interest
(QMEForm120) Voluntary Directive For Alternate Service Of Medical-Legal Evaluation Report On Disputed Injury To Psyche - 2/09
(QMEForm121) Declaration Regarding Protection Of Mental Health Record - 2/09
(QMEForm122) AME or QME Declaration of Service of Medical - Legal Report - 2/09
(QMEForm122) AME or QME Declaration of Service of Medical - Legal Report - 2/09
(QMEForm123) QME or AME Conflict of Interest Disclosure Form - 2/09
(QMEForm123Attachment) Instructions For Qme Form 123 - 2/09
(QMEForm124) Qme Disclosure Of Specified Financial Interests - 2/09