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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.

EAMS OCR forms	Number	Format
Court administrator forms
Compromise and release (Rev. 11/17/08)	DWC-CA form 10214(c)
Compromise and release (dependency claim) (Rev. 11/17/08)	DWC-CA form 10214(d)
Compromise and release (third party) (Rev. 11/17/08)	DWC-CA form 10214(e)
Declaration of readiness to proceed (Rev. 11/17/08)	DWC-CA form 10250.1
Declaration of readiness to proceed (expedited trial) (Rev. 11/17/08)	DWC-CA form 10252.1
Document cover sheet (Rev. 11/17/08)	DWC-CA form 10232.1
Document separator sheet (click paperclip for document titles and document types) (Rev. 11/17/08) Document separator sheet (without document titles list) Document titles list ( Rev. 11/14/08)	DWC-CA form 10232.2
Minutes of hearing (Rev. 11/17/08)	DWC-CA form 10245
Stipulations with request for award (Rev. 11/17/08)	DWC-CA form 10214(a)
Stipulations with request for award (death case) (Rev. 11/17/08)	DWC-CA form 10214(b)
Workers’ Compensation Appeals Board forms
Application for adjudication of claim (Rev. 11/17/08)	WCAB form 1
Answer to application for adjudication of claim (Rev. 11/17/08)	WCAB form 10
Notice and request for allowance of lien (Rev. 11/17/08)	DWC/WCAB form 6
Petition to terminate liability for temporary disability indemnity (Rev. 11/17/08)	WCAB form 46
Disability Evaluation Unit (DEU) forms
Employees permanent disability questionnaire (Rev. 11/17/08)	DWC-AD form 100 (DEU)
Request for consultative rating (RCR) (Rev. 11/17/08)	DWC-AD form 104 (DEU)
Request for reconsideration of summary rating by the administrative director (Rev. 11/17/08)	DWC-AD form 103 (DEU)
Request for summary rating determination - of AME's or QME's report (Rev. 11/17/08)	DWC-AD form101 (DEU)
Request for summary rating determination - primary treating physician report (Rev. 11/17/08)	DWC-AD form102 (DEU)
Retraining and Return to Work Unit (RRTW) forms
Notice of offer of modified or alternative work (Rev. 11/17/08)	DWC-AD form 10133.53 (SJDB)
Notice of offer of regular work (Rev. 11/17/08)	DWC-AD form 10118 (SJDB)
Notice of termination of vocational rehabilitation -10133.16 (Rev. 11/17/08)	RU form 105
Request for dispute resolution - 10133.14 (Rev. 11/17/08)	RU form 103
Request for dispute resolution before the administrative director (Rev. 11/17/08)	DWC-AD form 10133.55 (SJDB)
Request for reimbursement of accommodation expense (Rev. 11/17/08)	DWC-AD form 10120 (SJDB)
Settlement of prospective vocational rehabilitation services 10133.22 (Rev. 11/17/08)	RU form 122
Supplemental job displacement nontransferable training voucher (Rev. 11/17/08)	DWC-AD form 10133.57 (SJDB)
Vocational rehabilitation plan - 10133.13 (Rev. 11/17/08)	RU form 102
Uninsured Employers Benefits Trust Fund/Subsequent Injuries Benefits Trust Fund forms
Application for discretionary payments from the Uninsured Employers' Fund (Rev. 11/17/08)	DWC-UEF form 50
APPSIF-application for Subsequent Injuries Fund benefits (Rev. 11/17/08)

Legacy forms
Administrative forms	Number	Format
Arbitrator application
Arbitrator submittal form (Rev. 11/17/08)	DWC-CA form 10297
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 benefits for serious and willful misconduct of employer
Application for discrimination benefits pursuant to Labor Code section 132(A)
Information guidelines for submission of settlement documents
Medical mileage expense form in English/Spanish - for travel on or after 7/1/08 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 version
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 (Rev. 11/17/08)
Request for reconsideration of summary rating by the administrative director
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 - Oct. 25, 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
Commutation request
Employee's request for informal permanent disability rating	DEU 200
Notice of options following disability rating	DEU 110
Request for informal rating (by insurance carrier or self-insurer)	DEU 201
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
Progress report	RU 121
Request for conclusion	RB 105
Treating physician report of disability	RU 90
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

November 2008