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Division of Workers' Compensation (DWC)

Forms

fillable image Fillable form instructions fillable image = Fillable Adobe Acrobat form (en español) c = Adobe Acrobat for word image = Word form

Forms are listed by relevant subject, then in alphabetical order.

When identifying a claims administrator or representative on EAMS OCR forms, you must use the claims administrator or representative's uniform assigned name (UAN). Click on this link to search for a UAN.

If you are a claims administrator or representative and can't find your office in the UAN database, please submit your name, location, mailing address, telephone, e-mail, fax, or preferred method of service on letterhead with an authorized signature by e-mail to cru@dir.ca.gov or fax to (888) 822-9309. (Please note this is for claims administrators and representatives only.)

ZIP code locator tool will help you locate the DWC district office serving your ZIP code.

If you are an injured worker, you should be aware that, once an "Application for Adjudication of Claim" is filed, case file information, including case documents, may be disclosed under the California Public Records Act. Even in this circumstance, an injured worker's address and Social Security number are not revealed to the requestor by the DWC. The division uses this information solely to administer its duties in workers' compensation claims. Note that some case file information can be found by using the public information search tool, such as an injured worker's name, case number, case status, court location, employer name, a description of events in the case, and associated dates. It may list the parts of the body that were injured, but it does not include medical records or any case documents. The information provided in this search tool relates solely to cases in DWC's adjudication unit and is intended to help move cases through the court system efficiently. Any person requesting access to this information is required to identify themselves, state the reason for making the request, and instructed not to disclose the information to any person who is not entitled to it under Labor Code section 138.7.

Forms in this section:

EAMS OCR forms
Legacy forms
Administrative forms
Claim and court forms
Access to public records
Audit forms
Carve out agreement forms
Complaint forms
Disability evaluation forms
Fraud reporting forms
Independent Bill Review (IBR)
Independent Medical Review (IMR)
Judicial ethics forms
Lien filing and activation fees
Medical provider network (MPN) forms
Pre-designation of personal physician / Change of physician forms
Primary treating physician forms
Qualified medical evaluator (QME) and agreed medical evaluator (AME) forms
Supplemental Job Displacement Benefit (SJDB)
Utilization review forms

EAMS OCR forms - Court administrator forms Number Samples
Compromise and release (dependency claim) (Rev. 4/19/2010) fillable image DWC-CA 10214(d)
Compromise and release (Rev. 4/19/2010) fillable image DWC-CA 10214(c) Sample
Compromise and release (third party) (Rev. 4/19/2010) fillable image DWC-CA 10214(e)
Declaration of readiness to proceed (expedited trial) (Rev. 11/17/08) fillable image DWC-CA 10252.1 Sample
Declaration of readiness to proceed (Rev. 6/2011) fillable image DWC-CA 10250.1 Sample
Document cover sheet (Rev. 8/2/2010) fillable image
Body part codes list (Rev. 11/17/08)
Proof of service fillable image
DWC-CA 10232.1

Sample
Document separator sheet (click paperclip for document titles and document types) (Rev. 8/2/2010) fillable image
Document separator sheet (without document titles list)
Document titles list ( Rev. 2/22/2011) excel image
DWC-CA 10232.2
Lien conference disposition fillable image WCAB 27
Stipulations with request for award (death case) (Rev. 4/19/2010) fillable image DWC-CA 10214(b)
Stipulations with request for award (Rev. 4/19/2010) fillable image DWC-CA 10214(a) Sample
Supplement to minutes of hearing fillable image WCAB 20.1
EAMS OCR forms - Workers' Compensation Appeals Board forms Number Samples
Application for adjudication of claim (Rev. 4/19/2010) fillable image
How to submit an amended application for adjudication of claim
WCAB 1 Sample
Sample
Answer to application for adjudication of claim (Rev. 11/17/08) fillable image WCAB 10 Sample
Notice and request for allowance of lien (Rev. 11/17/08) fillable image WCAB 6 Sample
Petition to terminate liability for temporary disability indemnity (Rev. 11/17/08) fillable image WCAB 46 Sample
EAMS OCR forms - Disability Evaluation Unit (DEU) forms Number Samples
Employees permanent disability questionnaire (Rev. 11/17/08) fillable image En español DWC-AD 100
Request for consultative rating (RCR) (Rev. 11/17/08) fillable image DWC-AD 104 Sample
Request for reconsideration of summary rating by the administrative director
(Rev. 11/17/08) fillable image
DWC-AD 103
Request for summary rating determination of QME's report
(Rev. 4/19/2010) fillable image
DWC-AD 101 Sample
Request for summary rating determination - primary treating physician report
(Rev. 11/17/08) fillable image
DWC-AD 102 Sample
EAMS OCR forms - Uninsured Employers Benefits Trust Fund/Subsequent Injuries Benefits Trust Fund forms Number Samples
Application for discretionary payments from the Uninsured Employers' Fund
(Rev. 11/17/08) fillable image
DWC-UEF 50
APPSIF-application for Subsequent Injuries Fund benefits (Rev. 11/17/08) fillable image

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Legacy forms Number Samples
Administrative forms Number
Arbitrator application fillable image DWC-CA 10297
Arbitrator submittal form (Rev. 11/17/08) fillable image  
Doctor's first report of occupational injury or illness acrobat image DLSR 5021
EDEX client acknowledgment of legal constraints on access to information and use of information fillable image
EDEX client list fillable image
EDEX subscriber application fillable image
Employer's report of occupational injury or illness fillable image DLSR 5020
Notice to employees poster (English and Spanish) - 10/8/2010 fillable image DWC 7
Official medical fee schedule order form acrobat image
Physician's guide order form fillable image
Request for accommodations by persons with disability fillable image DWC 5

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Claim and court forms Number Samples
Addendum to application for adjudication of claim to identify legal entity employing injured worker fillable image WCAB 2
Appeal from determination and order of the Rehabilitation Unit fillable image
Application for adjudication of claim (Death case) fillable image DIA 2
Application for benefits for serious and willful misconduct of employer fillable image
Application for discrimination benefits pursuant to Labor Code section 132(A) - Sample
Attorney fee disclosure statement fillable image DWC 3
Declaration pursuant to Labor Code section 4906(g) fillable image
Information guidelines for submission of settlement documents acrobat image

Medical mileage expense form in English/Spanish fillable image - word image version
For travel on or after 1/1/14

Medical mileage expense form in English/Spanish fillable image - word image version
For travel on or after 1/1/13

Medical mileage expense form in English/Spanish fillable image - word image version
For travel on or after 7/1/11

Medical mileage expense form in English/Spanish fillable image - word image version
For travel on or after 1/1/11

Medical mileage expense form in English/Spanish fillable image - word image version
For travel on or after 1/1/10

Medical mileage expense form in English/Spanish fillable image - word image version
For travel on or after 1/1/09

Medical mileage expense form in English/Spanish fillable image - word image version
For travel on or after 7/1/08

Medical mileage expense form in English/Spanish fillable image - word image version
For travel on or after 1/1/08

Medical mileage expense form in English/Spanish fillable image - word image version
For travel on or after 1/1/07

Medical mileage expense form in English/Spanish fillable image - word image version
For travel between 7/1/06 and 1/1/07

I&A mileage form
Minutes of hearing fillable image WCAB 20
Minutes of hearing (addendum) fillable image WCAB 20.2
Notice of dismissal of attorney fillable image DWC WCAB 37
Notice of employee death acrobat image DIA 510
Objection to treating physician's recommendation for spinal surgery fillable image DWC form 233
Petition for appointment of guardian ad litem and trustee fillable image DWC WCAB 8
Petition for change of primary treating physician fillable image DWC 280
Petition for commutation of future payments fillable image DWC WCAB 49
Petition for reconsideration fillable image DWC WCAB 45
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.fillable image
DWC WCAB 42
Pre -trial conference statement lien issues addendum fillable image WCAB 24.1
Pre-trial conference statement WCAB 24
Pre-trial conference statement (Rev. 9/2010) fillable image DWC CA 10253.1
Special notice of lawsuit fillable image
Substitution of attorneys fillable image DWC WCAB 36 Sample
Workers' compensation claim form - effective 10/8/2010 fillable image DWC 1

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Access to public records Number Samples
Request for Public Records fillable image
Request for authorization number form fillable image DWC AD 3

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Utilization review forms Number Samples
Utilization review complaint form fillable image - word image version
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 1

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Fraud reporting forms Number Samples
Report of suspected medical care provider fraud fillable image DWC SMBFR 1115

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Independent Bill Review (IBR) forms Number Samples
updated image Request for Independent Bill Review acrobat image DWC Form IBR-1
updated image Provider's Request for Second Bill Review DWC Form SBR-1

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Independent Medical Review (IMR) forms Number Samples
updated image Application for Independent Medical Review fillable image DWC IMR
updated image Request for Authorization for Medical Treatment fillable image 9785.5

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Judicial ethics forms Number Samples
Complaint form and information fillable image

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Lien filing and activation fees Number Samples
Lien filing and activation fees fillable image Form A

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Pre-designation of personal physician / Change of physician forms Number Samples
Notice of personal chiropractor or personal acupuncturist fillable image - En español acrobat image DWC 9783.1
Notice of pre-designation of personal physician fillable image - En español acrobat image DWC 9783

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Primary treating physician forms Number Samples
Primary treating physician's permanent and stationary report fillable image
2005 permanent disability rating schedule
DWC
PR-4

Primary treating physician's permanent and stationary report fillable image
1997 permanent disability rating schedule
DWC
PR-3
Primary treating physician's progress report fillable image DWC
PR-2

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Qualified medical evaluator (QME) and agreed medical evaluator (AME) forms Number Samples
Additional panel request fillable image
QME 31.7
AME or QME declaration of service of medical - legal report fillable image QME 122
Application for accreditation or re-accreditation as education provider fillable image - Instructions acrobat image QME 118
Application for appointment as qualified medical evaluator fillable image QME 100
Course Evaluation for Administrative Director QME 117
Declaration regarding protection of mental health record fillable image QME 121
Faculty disclosure of commercial interest fillable image QME 119
QME appointment notification form fillable image QME 110
QME disclosure of specified financial interests fillable image QME 124
QME notice of unavailability fillable image QME 109
QME or AME conflict of interest disclosure form and objection or waiver fillable image Instructions acrobat image QME 123
QME/AME report time frame extension request fillable image QME 112
Qualified medical evaluator's findings summary form (unrepresented cases only) fillable image QME 111
Reappointment application as qualified medical evaluator fillable image QME 104
Registration for QME competency examination fillable image QME 102
Replacement panel request fillable image QME 31.5
Represented additional panel - Proof of service  
Represented replacement panel - Proof of service  
Request for Factual Correction of a Unrepresented Panel QME Report QME 37
Request For QME panel under Labor Code Section 4062.1 - Unrepresented fillable image
QME 105
Request For QME panel under Labor Code Section 4062.1 (Spanish) - Unrepresented fillable image
QME 105
Request For QME panel under Labor Code Section 4062.2 - Represented fillable image
QME 106
Unrepresented additional panel - Proof of service  
Unrepresented replacement panel - Proof of service  
Voluntary directive for alternate service of medical-legal evaluation report on disputed injury to psyche fillable image QME 120

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Supplemental Job Displacement Benefit Number Samples
Notice of Offer of Regular Work
Injuries occurring between 1/1/05 - 12/31/12, Inclusive fillable image
DWC - AD 10118
Supplemental Job Displacement Non-Transferable Voucher
Injuries occurring on or after 1/1/13 fillable image
DWC - AD 10133.32
Description Of Employee's Job Duties fillable image DWC - AD 10133.33
Notice of Offer Of Regular Modified Or Alternative Work
Injuries occurring on or after 1/1/13 fillable image
DWC - AD 10133.35
Physician's Return-to-Work & Voucher Report fillable image DWC - AD 10133.36
Notice Of Offer Of Modified Or Alternative Work
Injuries occurring between 1/1/04 - 12/31/12 fillable image
DWC - AD 10133.53
Request for Dispute Resolution Before Administrative Director fillable image DWC - AD 10133.55
Supplemental Job Displacement Nontransferable Training Voucher
Injuries occurring between 1/1/04 - 12/31/12 fillable image
DWC - AD 10133.57

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Disability evaluation forms Number Samples
Apportionment fillable image DEU 105
Commutation request Excel image
Notice of options following disability rating - En español acrobat image DEU 110

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Medical provider network (MPN) forms Number Samples
Cover page for medical provider network application fillable image DWC 9767.4
Independent medical review application fillable image - En español fillable image
For injured workers who need to get an independent medical review)

DWC 9768.10
Notice of medical provider network plan modification Labor Code 9767.8 - 10/8/2010 fillable image
DWC 9767.8
Physician contract application fillable image
for doctors who want to become independent medical reviewers
DWC 9768.5
Sample initial written employee notification re: Medical provider network acrobat image - version word image

Ejemplo de la notificación inicial escrita del empleado sobre la Red de proveedores médicosacrobat image - version word image

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Audit forms Number Samples
Audit referral form fillable image DWC-AU-906
Annual report of adjusting locations for claims administrators whose ARI requirements have been waived fillable image DWC-857
Audit report of inventory 2012 fillable image DWC-851
How to file a complaint with the Audit Unit acrobat image DWC-AU -905

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Carve out agreement forms Number Samples
Petition for permission to negotiate a section 3201.7 labor-management agreement fillable image DWC RGS-1

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Complaint forms Number Samples
How to file a complaint with the Audit Unit acrobat image DWC-AU -905
Qualified medical evaluator (QME) complaint form fillable image
Utilization review complaint form fillable image DWC -UR 1

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February 2014