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Form |
Description |
| DLSR-5020.pdf | Employer's Report of Occupational Injury or Illness - 6/02 |
| DLSR-5021.pdf | Doctor's First Report of Occupational Injury or Illness - 1992 |
| Court Administrator Forms | |
| DWC-10214c.pdf | Compromise And Release - 4/10 |
| DWC-10214d.pdf | Compromise and release (dependency claim) - 4/10 |
| DWC-10214e.pdf | Compromise And Release (third party) - 4/10 |
| DWC-CA-10250_1.pdf | Declaration Of Readiness To Proceed - 6/11 |
| DWC-CA-10232_1.pdf | DWC-CA form 10232.1 Document Cover Sheet - 8/10 |
| DWC-CA-10232_ver3.pdf | DWC-CA form 10232.1 Document Separator Sheet - 8/10 |
| DWC-CA-10252_1.pdf | Declaration Of Readiness To Proceed To Expedited Hearing (Trial) - 11/08 |
| DWC-CA-10232_2.pdf | Document Separator Sheet - 7/10 |
| DWC-CA-10232_2only.pdf | Document Separator Sheet - 11/08 |
| DWC-10245.pdf | Minutes Of Hearing - 11/08 |
| DWC-AD-10253_1.pdf | Pre-trial conference Statement - 9/10 |
| DWC-10214a.pdf | Stipulations With Request For Award - 4/10 |
| DWC-10214b.pdf | Stipulations With Request For Award (Death Case) - 4/10 |
| Workers' Compensation Appeals Board Forms | |
| DWC-WCAB-1.pdf | Application for Adjudication of Claim - 4/10 |
| DWC-10.pdf | Answer To Application For Adjudication Of Claim - 11/08 |
| DWC-6.pdf | Notice and Request For Allowance of Lien - 11/08 |
| DWC-46.pdf | Petition To Terminate Liability For Temporary Disability Indemnity - 11/08 |
| Disability Evaluation Unit (DEU) Forms | |
| DEU-100.pdf | Employee's Permanent Disability Questionnaire - 11/08 |
| DEU-104.pdf | Request For Consultative Rating - 11/08 |
| DEU-103.pdf | Request for Reconsideration of Summary Rating by the Administrative Director - 11/08 |
| DEU-101.pdf | Request for Summary Rating Determination (of AME's or QME's Report) - 4/10 |
| DEU-102.pdf | Request for Summary Rating Determination (of Primary Treating Physician's Report) - 11/08 |
| Retraining and Return to Work Unit (RRTW) Forms | |
| DWC-AD-10133.53.pdf | Notice Of Offer Of Modified Or Alternative Work - 11/08 |
| DWC-AD-10133.53_sp.pdf | Noticia De Oferta De Trabajo Modificado O Alternativo - 8/06 |
| DWC-AD-10118.pdf | Notice Of Offer Of Regular Work - 11/08 |
| DWC-AD-10133_55.pdf | Request For Dispute Resolution Before Administrative Director - 11/08 |
| DWC-AD-10133_57.pdf | Supplemental Job Displacement Nontransferable Training Voucher Form - 11/08 |
| Uninsured Employers Benefits Trust Fund/Subsequent Injuries Benefits Trust Fund Forms | |
| UEF50.pdf | Application For Discretionary Payments From The Uninsured Employers' Fund - 11/08 |
| SIFApplication.pdf | Application For Subsequent Injuries Fund Benefit - 11/08 |
| Legacy Administrative Forms | |
| ArbitrationApplication.pdf | Arbitrator Application - 3/09 |
| DWC-CA-10297.pdf | Arbitration Submittal Form - 11/08 |
| EDEX_client.pdf | EDEX client acknowledgment of legal constraints ... - 6/06 |
| EDEX_clientlist.pdf | EDEX Client List - 6/06 |
| EDEX_subscriber.pdf | EDEX Subscriber Application - 6/06 |
| DWC-5.pdf | Request for Accommodations by Persons with Disabilities - 9/09 |
| Claim and Court Forms | |
| AFD.pdf | Appeal From Determination And Order Of The Rehabilitation Unit - N/D |
| Seriousandwillful.pdf | Application For Benefits For Serious And Willful Misconduct Of Employer - N/D |
| ADB-132a.pdf | Application For Discrimination Benefits Pursuant To Labor Code - N/D |
| setguide.pdf | Information Guidelines For Submission Of Settlement Documents - N/D |
| mileage12.pdf | Medical mileage expense form in English/Spanish - for travel on or after 7/1/11 |
| mileage11.pdf | Medical mileage expense form in English/Spanish - for travel on or after 1/1/11 |
| mileage10.pdf | Medical Mileage Expense Form - 12/09 |
| mileage09.pdf | Medical Mileage Expense Form - 1/09 |
| mileage0708.pdf | Medical mileage expense form in English/Spanish - for travel on or after 7/1/08 |
| mileage08.pdf | Medical mileage expense form in English/Spanish - for travel on or after 1/1/08 |
| mileage07.pdf | Medical mileage expense form in English/Spanish - for travel on or after 1/1/07 |
| mileage06.pdf | Medical mileage expense form in English/Spanish - for travel between 7/1/06 and 1/1/07 |
| DIA-510.pdf | Notice of Employee Death - 9/84 |
| DWC-37.pdf | Notice of Dismissal of Attorney - 8/75 |
| DWC-233.pdf | Objection To Treating Physician's Recommendation For Spinal Surgery - 5/07 |
| DWC-8.pdf | Petition for Appointmentof Guardian ad Litem and Trustee - 10/90 |
| DWC-280.pdf | Petition for Change of Primary Treating Physician - 1/01 |
| DWC-45.pdf | Petition for Reconsidertion - 3/76 |
| DWC-49.pdf | Petition for Commutation of Future Payments - 11/74 |
| DWC-42.pdf | Petition to Reopen - 8/85 |
| DWC-AD-10253_1.pdf | PreTrial Conference Statement - 9/10 |
| DWC-1.pdf | Workers' Compensation Claim form (Employee) - 10/10 |
| DWC-1-2010.pdf | Workers' Compensation Claim form (Employee) - 6/10 EFFECTIVE 10-8-2010 |
| Access to Public Records | |
| PublicRecordsRequest.pdf | Request for Public Records - 5/11 |
| DWC_RequestAuthorizationNumberForm.pdf | Request for Authorization Number Form - 5/06 |
| Utilization Review Forms | |
| DWC-UR1.pdf | Utilization Review Complaint Form - N/D |
| Fraud Reporting Forms | |
| DWC-SMBFR-1115.pdf | Report of Suspected Medical Care Provider Fraud - 3/06 |
| Judicial Ethics Forms | |
| Ethform.pdf | Complaint and Information - N/D |
| Pre-designation of Personal Physician | |
| DWC-9783_1.pdf | Notice Of Personal Chiropractor Or Personal Acupuncturist - 3/06 |
| DWC-9783_1_sp.pdf | Noticia De Quiropráctico Personal O Acupuntor Personal - 3/06 |
| DWC-9783.pdf | Predesignation Of Personal Physician - 3/07 |
| DWC-9783_sp.pdf | Designación Previa De Médico Particular - 3/07 |
| Primary Treating Physician Forms | |
| PR-4.pdf | Primary Treating Physician's Permanent and Stationary Report (pursuant to 2005) - 6/05 |
| PR-3.pdf | Primary Treating Physician's Permanent and Stationary Report (pursuant to 1997) - 6/05 |
| PR-2.pdf | Primary Treating Physician's Progress Report - 6/05 |
| Qualified Medical Evaluator (QME) and Agreed Medical Evaluator (AME) Forms | |
| QMEForm122.pdf | AME or QME Declaration of Service of Medical - Legal Report - 2/09 |
| QMEForm118.pdf | Application For Accreditation Or Re-Accreditation As Education Provider - 2/09 |
| QMEForm118Attachent.pdf | Application For Accreditation as an Education Provider Instructions- 2/09 |
| QMEForm100.pdf | Application For Appointment As Qualified Medical Evaluator - 2/09 |
| QMEForm121.pdf | Declaration Regarding Protection Of Mental Health Record - 2/09 |
| QMEForm119.pdf | Faculty Disclosure Of Commercial Interest - 2/09 |
| QMEForm110.pdf | QME Appointment Notification Form - 2/09 |
| QMEForm124.pdf | QME Disclosure Of Specified Financial Interests - 2/09 |
| QMEForm109.pdf | QME Notice Of Unavailability (Form must be filed 30 days prior to date of unavailability) - 2/09 |
| QMEForm123.pdf | QME or AME Conflict of Interest Disclosure Form - 2/09 |
| QMEForm112.pdf | QME/AME Report Time Frame Extension Request - 2/09 |
| QMEForm111.pdf | Qualified Medical Evaluator\'s Findings Summary Form Unrepresented Injured Employee Cases Only 2/09 |
| QMEForm104.pdf | Reappointment Application As Qualified Medical Evaluator - 2/09 |
| QMEForm102.pdf | Registration For Qme Competency Examination - 2/09 |
| QMEForm105Spanish.pdf | División De Compensación De Trabajadores ? Unidad Médica Solicitud Para Un Panel De Qme Bajo El Código Laboral § 4062.1 Sin Representación - 2/09 |
| QMEForm105Attachment.pdf | How To Request A Qualified Medical Evaluator If You Do Not Have An Attorney Instructions - 2/09 |
| QMEForm105.pdf | Medical Unit Request For Qme Panel Under Labor Code § 4062.1 Unrepresented - 2/09 |
| QMEForm106Attachment.pdf | How To Request A Qualified Medical Evaluator In A Represented Case Instructions - 2/09 |
| QMEForm106.pdf | Medical Unit Request For QME Panel Under Labor Code § 4062.2 Represented - 2/09 |
| QMEForm120.pdf | Voluntary Directive For Alternate Service Of Medical-Legal Evaluation Report On Disputed Injury To Psyche - 2/09 |
| QMEForm123Attachment.pdf | Instructions For QME Form 123 - 2/09 |
| Spinal Surgery Second Opinion Forms | |
| DWC-232.pdf | Application For Spinal Surgery 2nd Opinion Physician List - 5/07 |
| Disability Evaluation Forms | |
| DEU-105.pdf | Apportionment - 1/05 |
| DEU-110.pdf | Notice of Options Following Permanent Disability Rating - 6/05 |
| DEU-200.pdf | Employee's Request for Information Permanent Disability Rating - 8/79 |
| DEU-110_sp.pdf | Aviso De Opciones Después De La Clasificación De Incapacidad - N/D |
| DEU-201.pdf | Request for Informal Rating (by Insurance Carrier or Self-Insurer) - 8/90 |
| MPN-form.pdf | DWC 9764.4 Cover page for medical provider network - 5/07 |
| IndependentMedicalReviewApplication_sp.pdf | DWC 9768.10 Solicitud de Revisión Médica Independiente - 5/07 |
| IndependentMedicalReviewApplication.pdf | DWC 9768.10 Independent Medical Review Application - 5/07 |
| MPN_MaterialModification.pdf | DWC 9767.8 Notice of medical provider network plan modification - 8/10 |
| IMRcontractReviewer.pdf | DWC 9768.5 Physician Contract Application (Independent Medical Reviewer - 5/07 |
| MPN_SampleInitialWrittenEmployeeNotificationLetter.pdf | Initial Written Employee Notification Re: Medical Provider Network - 6/07 |
| MPN_SampleInitialWrittenEmployeeNotificationLetter_sp.pdf | Notificación Inicial Escrita del Empleado sobre la Red de Proveedores Médicos - 6/07 |
| Audit Forms | |
| DWC-AU-905.pdf | Audit Referral Form - 11/06 |
| AdjustingLocations.pdf | Annual report of adjusting locations for claims administrators whose ARI requirements have been waived - 1/11 |
| DWC-851.pdf | Audit report of inventory 2011 - 1/11 |
| DWC-AU-906.pdf | How to File a Complaint with the Audit Unit - 6/06 |
| Carve Out Agreement Forms | |
| DWC-RGS-1.pdf | Petition for Permission to Negotiate a Section 3201.7 Labor-Management Agreement - 1/04 |
| Misc Forms | |
| notice-poster.pdf | POSTER - Notice to Employees Poster (English and Spanish) - Effective 10/8/2010 |
| Facts_WC.pdf | BROCHURE - Facts About Workers' Compensation (New Hire brochure) |
| TimeOfHirePamphlet.pdf | BROCHURE - Facts About Workers' Compensation (Time of Hire Pamphlet from CA DWC) |
| TimeofHirePamphlet_Spanish.pdf | BROCHURE - Facts About Workers' Compensation - SPANISH(Time of Hire Pamphlet from CA DWC) |
| Facts_IW.pdf | BROCHURE - Facts for Injured Workers |
| SELF INSURANCE FORMS | |
| SIP-A4-100.pdf | Application for Self Insurance Administrator's Examination - 12/97 |
| SIP-A4-1.pdf | Application for a Certificate of Consent to Self Insure - 2/92 |
| SIP-A4-2.pdf | Application for a Public Entity Certificate of Consent to Self Insure - 2/92 |
| SIP-A4-50.pdf | Application for a Certificate of Consent to Administer Workers' Compensation Self Insurance Claims - 8/96 |
| SIP-4-3.pdf | Application for a certificate of consent to self insure by a group of employers - 1/94 |
| SIP-A4-3M.pdf | Application For An Affiliate Certificate Of Consent - 1/94 |
| SIP-4-5.pdf | Application for a Permanent Certificate of Consent to Self Insure by an Interim Self Insurer - 11/97 |
| SIP-4-6.pdf | Agreement of Assumption and Guarantee of Workers' Compensation Liabilities - 11/97 |
| SIPCorpResolution.pdf | Corporate Resolution Authorizing Application - N/D |
| GAI_request.pdf | Request For Interim Certificate For Group Member - N/D |
| SIPintcer.pdf | Request For Interim Certificate - N/D |
| SIPinfo.pdf | Information Bulletin: Approved Securities - N/D |
| SIPinfotrust.pdf | Information Bulletin: Cash in Trust - N/D |
| SIPinfo1.pdf | Information Bulletin: Letter of Credit - N/D |
| SIPinfo2.pdf | Information Bulletin: Surety Bond - 12/01 |
| Rehab Services | |
| RB-105.pdf | Request for Conclusion - 1/03 |
| RB-107.pdf | Declination for Date Of Injury's pre 1/1/90 |
| RU-90.pdf | Treating Physician Report of Disability - 12/90 |
| RU-91.pdf | Description of Job Duties - 1/95 |
| RU-94.pdf | Notice of Offer of Modified or Alternate Work - 1/03 |
| RU-102.pdf | Rehabilitation Plan - 11/08 |
| RU-103.pdf | Request for Dispute Resolution - 11/08 |
| RU-105.pdf | Notice of Termination - 11/08 |
| RU-107.pdf | Declination for Date Of Injury's 1-1-90 - 12-31-93 (12/02) |
| RU-107A.pdf | Declination for Date Of Injury's (1/94) |
| RU-120.pdf | Evaluation Summary - 1/03 |
| RU-121.pdf | Progress Report - 9/98 |
| RU-122.pdf | Settlement Prospective of Voc Rehab Services - 11/08 |
| FormIMC81556.pdf | Treating Physician?s Determination Of Medical Issues - 4/95 |