Forms

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
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
Spinal surgery second opinion forms
Supplemental Job Displacement Benefit (SJDB)
Utilization review forms

EAMS OCR forms - Court administrator forms	Number	Samples
Document cover sheet (Rev. 8/2/2010) Body part codes list (Rev. 11/17/08) Proof of service	DWC-CA 10232.1	Sample
Document separator sheet (click paperclip for document titles and document types) (Rev. 8/2/2010) Document separator sheet (without document titles list) Document titles list ( Rev. 2/22/2011)	DWC-CA 10232.2
Compromise and release (Rev. 4/19/2010)	DWC-CA 10214(c)	Sample
Compromise and release (dependency claim) (Rev. 4/19/2010)	DWC-CA 10214(d)
Compromise and release (third party) (Rev. 4/19/2010)	DWC-CA 10214(e)
Declaration of readiness to proceed (Rev. 6/2011)	DWC-CA 10250.1	Sample
Declaration of readiness to proceed (expedited trial) (Rev. 11/17/08)	DWC-CA 10252.1	Sample
Minutes of hearing (Rev. 11/17/08)	DWC-CA 10245
Stipulations with request for award (Rev. 4/19/2010)	DWC-CA 10214(a)	Sample
Stipulations with request for award (death case) (Rev. 4/19/2010)	DWC-CA 10214(b)

EAMS OCR forms - Workers' Compensation Appeals Board forms	Number	Samples
Application for adjudication of claim (Rev. 4/19/2010) 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)	WCAB 10	Sample
Notice and request for allowance of lien (Rev. 11/17/08)	WCAB 6	Sample
Petition to terminate liability for temporary disability indemnity (Rev. 11/17/08)	WCAB 46	Sample

EAMS OCR forms - Disability Evaluation Unit (DEU) forms	Number	Samples
Employees permanent disability questionnaire (Rev. 11/17/08) En español	DWC-AD 100
Request for consultative rating (RCR) (Rev. 11/17/08)	DWC-AD 104	Sample
Request for reconsideration of summary rating by the administrative director (Rev. 11/17/08)	DWC-AD 103
Request for summary rating determination of QME's report (Rev. 4/19/2010)	DWC-AD 101	Sample
Request for summary rating determination - primary treating physician report (Rev. 11/17/08)	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)	DWC-UEF 50
APPSIF-application for Subsequent Injuries Fund benefits (Rev. 11/17/08)

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Legacy forms	Number	Samples
Administrative forms	Number
Arbitrator application	DWC-CA 10297
Arbitrator submittal form (Rev. 11/17/08)	DLSR 5021
Doctor's first report of occupational injury or illness
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 to employees poster (English and Spanish) - 10/8/2010	DWC 7
Official medical fee schedule order form
Physician's guide order form
Request for accommodations by persons with disability	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	WCAB 2
Appeal from determination and order of the Rehabilitation Unit
Application for adjudication of claim (Death case)	DIA 2
Application for benefits for serious and willful misconduct of employer
Application for discrimination benefits pursuant to Labor Code section 132(A) - Sample
Attorney fee disclosure statement	DWC 3
Declaration pursuant to Labor Code section 4906(g)
Information guidelines for submission of settlement documents
Medical mileage expense form in English/Spanish - version For travel on or after 1/1/13 Medical mileage expense form in English/Spanish - version For travel on or after 7/1/11 Medical mileage expense form in English/Spanish - version For travel on or after 1/1/11 Medical mileage expense form in English/Spanish - version For travel on or after 1/1/10 Medical mileage expense form in English/Spanish - version For travel on or after 1/1/09 Medical mileage expense form in English/Spanish - version For travel on or after 7/1/08 Medical mileage expense form in English/Spanish - version For travel on or after 1/1/08 Medical mileage expense form in English/Spanish - version For travel on or after 1/1/07 Medical mileage expense form in English/Spanish - version For travel between 7/1/06 and 1/1/07	I&A mileage form
Notice of employee death	DIA 510
Notice of dismissal of attorney	DWC WCAB 37
Objection to treating physician's recommendation for spinal surgery	DWC form 233
Petition for appointment of guardian ad litem and trustee	DWC WCAB 8
Petition for change of primary treating physician	DWC 280
Petition for reconsideration	DWC WCAB 45
Petition for commutation of future payments	DWC WCAB 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 42
Pre-trial conference statement (Rev. 9/2010)	DWC CA 10253.1
Special notice of lawsuit
Substitution of attorneys	DWC WCAB 36	Sample
Workers' compensation claim form - effective 10/8/2010	DWC 1

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

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Utilization review forms	Number	Samples
Utilization review complaint form - 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	DWC SMBFR 1115

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

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

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Judicial ethics forms	Number	Samples
Complaint form and information

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

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Primary treating physician forms	Number	Samples
Primary treating physician's permanent and stationary report 2005 permanent disability rating schedule	DWC PR-4
Primary treating physician's permanent and stationary report 1997 permanent disability rating schedule	DWC PR-3
Primary treating physician's progress report	DWC PR-2

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Qualified medical evaluator (QME) and agreed medical evaluator (AME) forms	Number	Samples
Additional panel request OPTIONAL for use when requesting an additional QME panel under QME regulation 31.7	QME 31.7 Opt.
AME or QME declaration of service of medical - legal report	QME 122
Application for accreditation or re-accreditation as education provider - Instructions	QME 118
Application for appointment as qualified medical evaluator	QME 100
Declaration regarding protection of mental health record	QME 121
Faculty disclosure of commercial interest	QME 119
QME appointment notification form	QME 110
QME disclosure of specified financial interests	QME 124
QME notice of unavailability	QME 109
QME or AME conflict of interest disclosure form and objection or waiver - Instructions	QME 123
QME/AME report time frame extension request	QME 112
Qualified medical evaluator's findings summary form (unrepresented cases only)	QME 111
Reappointment application as qualified medical evaluator	QME 104
Registration for QME competency examination	QME 102
Replacement panel request OPTIONAL for use when requesting a replacement QME panel under QME regulation 31.5	QME 31.5
Request for Factual Correction of a Unrepresented Panel QME Report	QME 37
Request For QME panel under Labor Code Section 4062.1 - Unrepresented attachment to form 105 - En español *To open attachment, open form then click on paperclip icon on left side margin, then double click on attachment Request For QME panel under Labor Code Section 4062.1 - Unrepresented - injuries on or after 1/1/13	QME 105
Request For QME panel under Labor Code Section 4062.2 - Represented - attachment to form 106 *To open attachment, open form then click on paperclip icon on left side margin, then double click on attachment Request For QME panel under Labor Code Section 4062.2 - Represented - injuries on or after 1/1/13	QME 106
Voluntary directive for alternate service of medical-legal evaluation report on disputed injury to psyche	QME 120

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Spinal surgery second opinion forms	Number	Samples
Application for spinal surgery second opinion physician list	DWC 232
Objection to treating physician's recommendation for spinal surgery	DWC 233

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

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

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Medical provider network (MPN) forms	Number	Samples
Cover page for medical provider network application	DWC 9767.4
Independent medical review application - En español 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	DWC 9767.8
Physician contract application for doctors who want to become independent medical reviewers	DWC 9768.5
Sample initial written employee notification re: Medical provider network - version Ejemplo de la notificación inicial escrita del empleado sobre la Red de proveedores médicos - version

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Audit forms	Number	Samples
Audit referral form	DWC-AU-906
Annual report of adjusting locations for claims administrators whose ARI requirements have been waived	DWC-857
Audit report of inventory 2012	DWC-851
How to file a complaint with the Audit Unit	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	DWC RGS-1

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

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January 2013