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Division of Workers' Compensation - Forms

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Forms are listed by relevant subject, then in alphabetical order. Click here for a list of forms by relevant subject and form number.

Administrative forms	Number	Format
Arbitrator application
Doctor's first report of occupational injury or illness	DLSR 5021
EDEX client acknowledgment of legal constraints on access to information and use of information
EDEX client list
EDEX subscriber application
Employer's report of occupational injury or illness	DLSR 5020
Notice of employee death	DIA 510
Notice to employees poster (English and Spanish)
Official medical fee schedule order form
Physician's guide order form
Request for accommodations by persons with disability	DWC form 5
Claim and court forms	Number	Format
Appeal from determination and order of the Rehabilitation Unit
Application for adjudication of claim	DWC WCAB form 1
Application for benefits for serious and willful misconduct of employer
Application for discrimination benefits pursuant to Labor Code section 132(A)
Compromise and release	DWC WCAB form 15
Declaration of readiness to proceed	DWC WCAB form 9
Declaration of readiness to proceed - expedited hearing (trial)	DWC WCAB form 4
Information guidelines for submission of settlement documents
Medical mileage expense form in English/Spanish - for travel on or after 1/1/08 Medical mileage expense form in English/Spanish - for travel on or after 1/1/07 Medical mileage expense form in English/Spanish - for travel between 7/1/06 and 1/1/07	I&A mileage form	version version version
Minutes of hearing/order/order and decision on request for continuance/order taking off calendar/notice of hearing
Notice and request for allowance of lien	DWC WCAB form 6
Notice of employee death	DIA 510
Notice of dismissal of attorney	DWC WCAB form 37
Objection to treating physician's recommendation for spinal surgery	DWC form 233
Petition for appointment of guardian ad litem and trustee	DWC WCAB form 8
Petition for change of primary treating physician	DWC form 280
Petition for reconsideration	DWC WCAB form 45
Petition for commutation of future payments	DWC WCAB form 49
Petition to reopen Note: A declaration of readiness to proceed must also be filed with this form. See I&A guide 11 for more detailed instructions.	DWC WCAB form 42
Pre-trial conference statement
Request for consultative rating
Request for reconsideration of summary rating by the administrative director
Stipulation and award and/or order	DWC WCAB form 5
Stipulations with request for award	DWC WCAB form 3
Workers' compensation claim form	DWC 1
Access to public records	Number	Format
Request for Public Records
Request for authorization number form	DWC form AD 3
Utilization review forms	Number	Format
Utilization review complaint form Note: If you want to save this form to your computer and email it to the DWC Medical Unit, you MUST use the Word version. The PDF version cannot be saved to your computer once filled	DWC UR form 1	version
Fraud reporting forms	Number	Format
Report of suspected medical care provider fraud	DWC form SMBFR 1115
Judicial ethics forms	Number	Format
Complaint form and information
Pre-designation of personal physician / Change of physician forms	Number	Format
Notice of personal chiropractor or personal acupuncturist Noticia de quiropráctico personal o acupuntor personal	DWC form 9783.1
Notice of pre-designation of personal physician Designación previa de médico particular	DWC form 9783
Primary treating physician forms	Number	Format
Primary treating physician's permanent and stationary report 2005 permanent disability rating schedule	DWC form PR-4
Primary treating physician's permanent and stationary report 1997 permanent disability rating schedule	DWC form PR-3
Primary treating physician's progress report	DWC form PR-2
Treating physician's determination of medical issues	IMC form 81556
Qualified medical evaluator (QME) and agreed medical evaluator (AME) forms Send all QME and AME forms to the following address, regardless of what the form indicates: DWC Medical Unit P.O. Box 71010 Oakland CA 94612	Number	Format
Application for accreditation or re-accreditation as education provider	IMC form 118
How to request a qualified medical evaluator Request for qualified medical evaluator	IMC form 105 IMC form 106
Notice of qualified medical evaluator unavailability	IMC form 109
QME/AME time frame extension request	IMC form 112
Qualified medical evaluator appointment notification form	IMC form 110
Qualified medical evaluator exam packet - Apr. 26, 2008
Qualified medical evaluator fees	IMC form 103
Qualified medical evaluator letter	IMC form 108
Qualified or agreed medical evaluator's findings summary	IMC form 111
Reappointment application as qualified medical evaluator	IMC form 104
Spinal surgery second opinion forms	Number	Format
Application for spinal surgery second opinion physician list	DWC 232
Objection to treating physician's recommendation for spinal surgery	DWC 233
Disability evaluation forms	Number	Format
Apportionment	DEU 105
Employee's permanent disability questionnaire	DEU 100
Employee's request for informal permanent disability rating	DEU 200
Notice of options following disability rating	DEU 110
Request for consultative rating
Request for informal rating (by insurance carrier or self-insurer)	DEU 201
Request for reconsideration of summary rating by the administrative director	DEU 103
Request for summary rating determination (of AME's or QME 's report)	DEU 101
Request for summary rating determination (of primary treating physician's report)	DEU 102
Vocational rehabilitation benefit forms	Number	Format
Declination for dates of injury 1/1/90 - 12/31/93	RU 107
Declination for dates of injury post 1/1/94	RU 107A
Declination for dates of injury pre 1/1/90	RB 107
Description of job duties	RU 91
Evaluation summary	RU 120
Notice of offer of modified or alternate work	RU 94
Notice of termination	RU 105
Progress report	RU 121
Rehabilitation plan	RU 102
Request for conclusion	RB 105
Request for dispute resolution and instructions	RU 103
Settlement of prospective vocational rehabilitation services	RU 122
Treating physician report of disability	RU 90
Supplemental job displacement benefit forms	Number	Format
Notice of offer of modified or alternative work Injuries occurring on or after 1/1/04 - effective Aug. 18, 2006 Noticia de oferta de trabajo modificado o alternativo Para lesiones ocurriendo el o despu?s del 1/1/04	DWC-AD 10133.53
Request for dispute resolution before the administrative director Injuries occurring on or after 1/1/04 - effective Aug. 18, 2006	DWC-AD 10133.55
Supplemental job displacement nontransferable training voucher Injuries occurring on or after 1/1/04 - effective Aug 1, 2005	DWC-AD 10133.57
Return to work forms	Number	Format
Notice of offer of modified or alternative work Injuries occurring on or after 1/1/04 - effective Aug. 18, 2006 Noticia de oferta de trabajo modificado o alternativo Para lesiones ocurriendo el o despu?s del 1/1/04	DWC-AD 10133.53
Notice of offer of regular work Injuries occurring on or after 1/1/05 Noticia de oferta de trabajo regular Para lesiones ocurriendo el o despu?s del 1/1/05	DWC-AD 10003
Request for reimbursement of accommodation expenses Injuries on or after 7/1/ 04	DWC-AD 10005
Medical provider network (MPN) forms	Number	Format
Cover page for medical provider network application	DWC form 9767.4
Independent medical review application (for injured workers who need to get an independent medical review)
Notice of medical provider network plan modification ?9767.8	DWC form 9767.8
Physician contract application (for doctors who want to become independent medical reviewers)	DWC form 9768.5
Sample initial written employee notification re: Medical provider network Ejemplo de la notificación inicial escrita del empleado sobre la Red de proveedores médicos		version version
Audit forms	Number	Format
Audit referral form	DWC-AU-906
How to file a complaint with the Audit Unit	DWC-AU -905
Carve out agreement forms	Number	Format
Petition for permission to negotiate a section 3201.7 labor-management agreement	DWC form RGS-1

December 2007