1. DWC

Forms

Forms are grouped by relevant subject, then in alphabetical order. Use the arrows to change to reverse alphabetical order or search by form number. The ten most-downloaded forms also appear in the “Frequently used forms” section.

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Frequently used forms

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Form

Number
   
Request For QME panel under Labor Code Section 4062.1 - Unrepresented
Instructions
 QME 105
Replacement panel request QME 31.5
Minutes of hearing WCAB 20
Physician's return-to-work & voucher report DWC - AD 10133.36
Pre-trial conference statement WCAB 24
Workers' compensation claim form DWC 1
Supplemental job displacement non-transferable voucher
* Injuries occurring on or after 1/1/13
DWC - AD 10133.32
Medical mileage expense form English/Spanish
* For travel on or after 1/1/25
Mileage prior to 1/1/25
 Mileage form
Additional QME panel request QME 31.7
Request For QME panel under Labor Code Section 4062.2 - Represented
* injuries occurring prior to 1/1/05
Instructions
 QME 106
Notice to Employees - Injuries caused by work - English and Spanish DWC 7

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Audit forms

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Form

 Number
   

Audit referral form

 DWC-AU-906
Annual report of adjusting locations for claims administrators DWC-857
Audit report of inventory  DWC-851

Complaint form: Audit Unit

 DWC-AU-905

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Complaint forms

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Form

 Number
   
Complaint form: Utilization review DWC UR 1
Report of suspected medical care provider fraud  DWC SMBFR 1115
Complaint form: Workers' Compensation Judge  
Complaint form: Audit Unit DWC-AU -905
Complaint form: Qualified medical evaluator (QME)  
Complaint form: Medical Provider Network DWC 9767.16.5

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Court forms

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Form Number
Compromise and release - dependency claim DWC-CA 10214-d
Compromise and release - third party DWC-CA 10214-e
Declaration of readiness to proceed - expedited trial DWC-CA 10208.3
Declaration of readiness to proceed DWC-CA 10250.1
Document cover sheet DWC-CA 10232.1
Proof of service
Document separator sheet
 DWC-CA 10232.2
Stipulations with request for award - death case DWC-CA 10214-b
Stipulations with request for award
* For injury on or after 1-1-2013 		DWC-CA 10214-a
Stipulations with request for award
* For injury prior to 1-1-2013 		DWC-CA 10214-a
Supplement to minutes of hearing WCAB 20.1
Application for adjudication of claim
* How to submit an amended application for adjudication of claim		 WCAB 1
Answer to application for adjudication of claim WCAB 10
Notice and request for allowance of lien WCAB 6
Petition to terminate liability for temporary disability indemnity WCAB 46
Arbitrator submittal DWC-CA form 10297
Arbitrator Application
Request for accommodations by persons with disability DWC 5
Addendum to application for adjudication of claim to identify legal entity employing injured worker WCAB 2
Application for adjudication of claim - Death case DIA 2
Application for benefits for serious and willful misconduct of employer
Verification form
Application for discrimination benefits pursuant to Labor Code section 132 - A
Verification form

Attorney Fee Disclosure Statement

 DWC 3
Declaration pursuant to Labor Code section 4906(h)
Minutes of hearing WCAB 20
Minutes of hearing - addendum WCAB 20.2
Notice of dismissal of attorney DWC WCAB 37
Notice of employee death DIA 510
Petition for appointment of guardian ad litem and trustee DWC WCAB 8
Petition for change of primary treating physician DWC 280
Petition for commutation of future payments
Verification form
 DWC WCAB 49
Petition for reconsideration DWC WCAB 45
Petition to reopen
Verification form
DWC WCAB 42
Pre-trial conference statement WCAB 24
Pre-trial conference statement lien issues addendum WCAB 24.1
Special notice of lawsuit
Substitution of attorneys DWC WCAB 36
Verification
Compromise and release DWC-CA 10214-c
Information guidelines for submission of settlement documents
Subpoena Duces Tecum DWC WCAB 32
Subpoena DWC WCAB 30

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Disability Evaluation forms

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Form

 Number
   
Employee's permanent disability questionnaire DWC-AD 100
Request for consultative rating DWC-AD 104
Request for reconsideration of summary rating by the administrative director DWC-AD 103
Request for summary rating determination of Qualified Medical Evaluator's (QME) Report DWC-AD 101
Request for summary rating determination - primary treating physician report DWC-AD 102
Apportionment request  DEU 105
Commutation request  

Notice of options following disability rating

DEU 110

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Employer forms

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Form

 Number
   
Workers' compensation claim form DWC 1
Employer's report of occupational injury or illness DLSR 5020
Petition for permission to negotiate a section 3201.7 labor-management agreement DWC RGS-1

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Independent Bill Review forms

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Form

 Number
   
Provider's request for second bill review DWC Form SBR-1
Request for independent bill review DWC Form IBR-1

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Independent Medical Review forms

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Form

 Number
   
Application for Independent Medical Review DWC IMR
Petition appealing administrative director’s independent medical review determination
Verification form
  

Independent medical review application

* For injured workers who need to get an independent medical review

 DWC 9768.10
Physician contract application
* For doctors who want to become independent medical reviewers		 DWC 9768.5

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Lien forms

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Form

 Number
   
Lien filing fees refund request Form A
Lien conference disposition WCAB 27

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Medical forms

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Form

 Number
   
Doctor's first report of occupational injury or illness
Tips for using this form
5021
Primary treating physician's permanent and stationary report 
* 2005 permanent disability rating schedule
Tips for using this form
DWC PR-4

Primary treating physician's permanent and stationary report 
* 1997 permanent disability rating schedule

Tips for using this form
DWC PR-3
Primary treating physician's progress report
Tips for using this form
DWC PR-2
Medical mileage expense form English/Spanish  
* For travel on or after 1/1/25
Mileage prior to 1/1/25
 Mileage form
Request for authorization for medical treatment 9785.5

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Medical Provider Network forms

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Form

 Number
   
Cover page for medical provider network application or plan for reapproval DWC 9767.4
Complaint form: Medical Provider Network DWC 9767.16.5
Disclosure of contract reimbursement rate DWC 5307.12
MPN response to petition for suspension or revocation of a medical provider network - Part B DWC 9767.17.5
Notice of medical provider network plan modification  DWC 9767.8
Petition for suspension or revocation of a medical provider network - Part A 
 DWC 9767.17.5

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Pre-designation forms

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Form

 Number
   
Notice of personal chiropractor or personal acupuncturist
DWC 9783.1
Notice of pre-designation of personal physician
 DWC 9783
Noticia de quiropráctico personal o acupuntor personal DWC 9783.1
Designación previa de médico personal DWC 9783

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Public records forms

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Form

Number
   
 Request for public records  
Request for authorization number form DWC AD 3

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QME/AME forms

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Form Number
   
Additional QME panel request QME 31.7
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
Course Evaluation for Administrative Director (QME) QME 117
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
Replacement panel request 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
Instructions
 QME 105
Solicitud De Panel De Evalua dor Medicó Calificado- Empleado sin representación legal

Instrucciones
 QME 105
Request For QME panel under Labor Code Section 4062.2 
* For injuries occurring prior to 1/1/05 Represented
Instructions

* Note: For injuries on or after 1/1/05, online only as of Oct. 1, 2015. No paper submissions postmarked after Sept. 3, 2015. 		QME 106
Voluntary directive for alternate service of medical-legal evaluation report on disputed injury to psyche QME 120
Complaint form: Qualified medical evaluator (QME)  
Notice to Injured Worker regarding QME Exam QME 108
Registration for QME competency examination QME 102

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SIBTF/UEBTF forms

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Form

 Number
   
Application for discretionary payments from the uninsured employers' fund DWC-UEF 50
Application for subsequent injuries fund benefits  
Payee Data Record STD 204

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Supplemental Job Displacement Benefits forms

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Form

 Number
   
Description Of Employee's Job Duties  DWC-AD 10133.33
Notice of Offer of Regular Work
* Injuries occurring between 1/1/05 - 12/31/12, Inclusive		 DWC-AD 10118
Supplemental Job Displacement Non-Transferable Voucher
* Injuries occurring on or after 1/1/13
 DWC-AD 10133.32
Notice of Offer Of Regular Modified Or Alternative Work
*  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
* Injuries occurring between 1/1/04 - 12/31/12		 DWC-AD 10133.53
Supplemental Job Displacement Nontransferable Training Voucher 
* Injuries occurring between 1/1/04 - 12/31/12
 DWC-AD 10133.57

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Comments? Questions? Suggestions? Email dwc@dir.ca.gov

 

March 2022