This area is only available to WorkCompResearch subscribers. WCR offers the most advanced Compliance and Regulatory Research System available.

Already a member? Log-in

Join Today for Immediate Access!


Sign Up


Home| Forms| Legal Library| Compliance| Calculators| State Comparisons| Reference Desk| What's New| Roundtable
Pre-select A State ↓ (Optional)   Current State: None   (← what's this?)

California Form Center -

Type & Print Forms - programmed for direct type and print functionality.

Each form may be downloaded in Adobe Acrobat format. Download the form by clicking on the form number below.
If you do not have Adobe Acrobat Reader, you may download it here for free. Download Adobe Here

All of these forms may now be auto-populated from your claims software program! Click here to learn about FlashForm SSL.


Form

Description

DLSR-5020.pdf Employer's Report of Occupational Injury or Illness
DLSR-5021.pdf Doctor's First Report of Occupational Injury or Illness
DWC-CA-10208.3.pdf Declaration of Readiness to Proceed (Expedited Trial)
DWC-10214a.pdf Stipulations with Request for Award (For injury prior to 1-1-2013)
DWC-10214a-1.pdf Stipulations with Request for Award(For injury on or after 1-1-2013)
DWC-10214b.pdf Stipulations with Request for Award (Death Case)
DWC-10214c.pdf Compromise and Release
DWC-10214d.pdf Compromise and Release (Dependency Claim)
DWC-10214e.pdf Compromise and Release (Third Party)
DWC-CA-10232.1.pdf Document Cover Sheet
DWC-CA-10232.2.pdf Document Separator Sheet
DWC-CA-10250.1.pdf Declaration of Readiness to Proceed
DWC-CA-10253.1.pdf PreTrial Conference Statement Notice of Hearing
WCABform20.pdf Minutes of Hearing
WCABForm20.1.pdf Supplement to Minutes of Hearing
WCABForm20.2.pdf Minutes of Hearing (addendum)
WCABForm24.pdf Pre-trial Conference Statement
WCABForm24.1.pdf Pre-trial Conference Statement Lien Issues (Addendum)
WCABForm27.pdf Lien Conference Disposition Form
DWC-WCAB-1.pdf Application for Adjudication of Claim
DWC-6.pdf Notice and Request for Allowance of Lien
DWC-10.pdf Answer to Application for Adjudication of Claim
DWC-46.pdf Petition to Terminate Liability for Temporary Disability Indemnity
DEU-100.pdf Employee's Permanent Disability Questionnaire
DEU-101.pdf Request for Summary Rating Determination (of AME's or QME's Report)
DEU-102.pdf Request for Summary Rating Determination (of Primary Treating Physician's Report)
DEU-103.pdf Request for Reconsideration of Summary Rating by the Administrative Director
DEU-104.pdf Request for Consultative Rating
DEU-105.pdf Apportionment
DEU-110.pdf Notice of Options Following Permanent Disability Rating
DEU-110_sp.pdf Notice of Options Following Permanent Disability Rating (Spanish)
DWC-AD-10118.pdf Notice of Offer of Regular Work for injuries occurring between 1/1/05 - 12/31/12, Inclusive
DWC-AD-10133.32.pdf Supplemental Job Displacement Non-Transferable Voucher Form- for injuries occurring on or after 1/1/13
DWC-AD-10133.33.pdf Description of Employee's Job duties
DWC-AD-10133.35.pdf Notice of Offer of Regular, Modified, or Alternative Work - for injuries occurring on or after 1/1/13
DWC-AD-10133.36.pdf Physician's Return to Work and Voucher Report
DWC-AD-10133.53.pdf Notice of Offer of Modified or Alternative Work - for injuries occurring between 1/1/04 - 12/31/12
DWC-AD-10133.53_sp.pdf Notice of Offer of Modified or Alternative Work (Spanish)
DWC-AD-10133_55.pdf Request for Dispute Resolution Before Administrative Director
DWC-AD-10133_57.pdf Supplemental Job Displacement Nontransferable Training Voucher Form - for injuries occurring between 1/1/04 - 12/31/12
UEF50.pdf Application for Discretionary Payments from the Uninsured Employers' Fund
SIFApplication.pdf Application for Subsequent Injuries Fund Benefit
ArbitrationApplication.pdf Arbitrator Application
DWC-CA-10297.pdf Arbitration Submittal Form
EDEX_client.pdf EDEX Client Acknowledgment of Legal Constraints
EDEX_clientlist.pdf EDEX Client List
EDEX_subscriber.pdf EDEX Subscriber Application
DWC-5.pdf Request for Accommodations by Persons with Disabilities
dwc3.pdf Attorney Fee Disclosure Statement
WCAB-2.pdf Addendum to Application for Adjudication of Claim to Identify Legal Entity Employing Injured Worker
AFD.pdf Appeal from Determination and Order of the Rehabilitation Unit
Seriousandwillful.pdf Petition for Benefits for Serious and Willful Misconduct of Employer Pursuant to Labor Code Section 4553
ADB-132a.pdf Petition For Discrimination Benefits Pursuant To Labor Code
setguide.pdf Information Guidelines for Submission of Settlement Documents
mileage17.pdf Medical Mileage Expense Form - for travel on or after 1/1/17 (English/Spanish)
mileage16.pdf Medical Mileage Expense Form - for travel on or after 1/1/16 (English/Spanish)
mileage15.pdf Medical Mileage Expense Form - for travel on or after 1/1/15 (English/Spanish)
mileage14.pdf Medical Mileage Expense Form - for travel on or after 1/1/14 (English/Spanish)
mileage13.pdf Medical Mileage Expense Form - for travel on or after 1/1/13 (English/Spanish)
mileage12.pdf Medical Mileage Expense Form - for travel on or after 7/1/11 (English/Spanish)
mileage11.pdf Medical Mileage Expense Form - for travel on or after 1/1/11 (English/Spanish)
mileage10.pdf Medical Mileage Expense Form - for travel on or after 1/1/10 (English/Spanish)
mileage09.pdf Medical Mileage Expense Form - for travel on or after 1/1/09 (English/Spanish)
mileage0708.pdf Medical Mileage Expense Form - for travel on or after 7/1/08 (English/Spanish)
mileage08.pdf Medical Mileage Expense Form - for travel on or after 1/1/08 (English/Spanish)
mileage07.pdf Medical Mileage Expense Form - for travel on or after 1/1/07(English/Spanish)
mileage06.pdf Medical Mileage Expense Form - for travel between 7/1/06 and 1/1/07 (English/Spanish)
DIA-510.pdf Notice of Employee Death
DWC-37.pdf Notice of Dismissal of Attorney
DWC-233.pdf Objection to Treating Physician's Recommendation for Spinal Surgery
DWC-8.pdf Petition for Appointmentof Guardian ad Litem and Trustee
DWC-280.pdf Petition for Change of Primary Treating Physician
DWC-45.pdf Petition for Reconsideration
DWC-49.pdf Petition for Commutation of Future Payments
DWC-42.pdf Petition to Reopen
DWC-1.pdf Workers' Compensation Claim form (Employee)
PublicRecordsRequest.pdf Request for Public Records
DWC_RequestAuthorizationNumberForm.pdf Request for Authorization Number Form
DWC-UR1.pdf Utilization Review Complaint Form
DWC-SMBFR-1115.pdf Report of Suspected Medical Care Provider Fraud
FormIBR_1.pdf Request for Independent Bill Review
FormSBR_1.pdf Provider's Request for Second Bill Review
IMRForm_Application.pdf Application for Independent Medical Review
IMRFormRFAClean.pdf Request for Authorization for Medical Treatment
Ethform.pdf Complaint and Information
DWC-9783_1.pdf Notice of Personal Chiropractor or Personal Acupuncturist
DWC-9783_1_sp.pdf Notice of Personal Chiropractor or Personal Acupuncturist (Spanish)
DWC-9783.pdf Predesignation of Personal Physician
DWC-9783_sp.pdf Predesignation of Personal Physician (Spanish)
PR-4.pdf Primary Treating Physician's Permanent and Stationary Report (pursuant to 2005)
PR-3.pdf Primary Treating Physician's Permanent and Stationary Report (pursuant to 1997)
PR-2.pdf Primary Treating Physician's Progress Report
QMEForm31_5.pdf Replacement Panel Request
QMEForm31_7.pdf Additional Panel Request
QMEForm37.pdf Request for Factual Correction of a Unrepresented Panel QME Report
QMEForm100.pdf Application for Appointment as Qualified Medical Evaluator
QMEForm102.pdf Registration for Qme Competency Examination
QMEForm104.pdf Reappointment Application as Qualified Medical Evaluator
QMEForm105.pdf Request For QME panel under Labor Code Section 4062.1 Unrepresented
QMEForm105inst.pdf Instructions- How to Request a Qualified Medical Evaluator if You do not have an Attorney (do not file with form)
QMEForm105_Spanish.pdf Request For QME panel under Labor Code Section 4062.1 - Unrepresented (Spanish)
QMEForm106.pdf Request For QME panel under Labor Code Section 4062.2 - Represented NOTE: For injuries on or after 1/1/05, online only as of Oct. 1, 2015. No paper submissions postmarked after Sept. 3, 2015.
QMEForm106Attachment.pdf How to Request a Qualified Medical Evaluator in a Represented Case Instructions
QMEForm109.pdf QME Notice of Unavailability (Form must be filed 30 days prior to date of unavailability)
QMEForm110.pdf QME Appointment Notification Form
QMEForm111.pdf Qualified Medical Evaluator's Findings Summary Form Unrepresented Injured Employee Cases Only
QMEForm112.pdf QME/AME Report Time Frame Extension Request
QMEForm117.pdf Course Evaluation for Administrative Director
QMEForm118.pdf Application for Accreditation or Re-Accreditation as Education Provider
QMEForm118Attachent.pdf Application for Accreditation as an Education Provider Instructions
QMEForm119.pdf Faculty Disclosure of Commercial Interest
QMEForm120.pdf Voluntary Directive for Alternate Service of Medical-Legal Evaluation Report on Disputed Injury to Psyche
QMEForm121.pdf Declaration Regarding Protection of Mental Health Record
QMEForm122.pdf AME or QME Declaration of Service of Medical - Legal Report
QMEForm123.pdf QME or AME Conflict of Interest Disclosure Form
QMEForm123Attachment.pdf Instructions for QME Form 123
QMEForm124.pdf QME Disclosure of Specified Financial Interests
ProofOfService.pdf Proof of Service Form
RepresentedAdditionalPanel_ProofOfService.pdf Represented Additional Panel - Proof of Service
RepresentedReplacementPanel_ProofOfService.pdf Represented Replacement Panel - Proof of Service
UnrepresentedAdditionalPanel_ProofOfService.pdf Unrepresented additional panel - Proof of Service
UnrepresentedReplacementPanel_ProofOfService.pdf Unrepresented Replacement Panel - Proof of Service
MPN-form.pdf Cover Page for Medical Provider Network
IndependentMedicalReviewApplication.pdf Independent Medical Review Application
IndependentMedicalReviewApplication_sp.pdf Independent Medical Review Application (Spanish)
MPN_MaterialModification.pdf Notice of Medical Provider Network Plan Modification
IMRcontractReviewer.pdf Physician Contract Application (Independent Medical Reviewer)
MPN_SampleInitialWrittenEmployeeNotificationLetter.pdf Initial Written Employee Notification Re: Medical Provider Network
MPN_SampleInitialWrittenEmployeeNotificationLetter_sp.pdf Initial Written Employee Notification Re: Medical Provider Network (Spanish)
MPNComplaintForm9767.16.5.Strikeout.pdf DWC Medical Provider Network Complaint Form 9767.16.5
DWCForm9767.17.5PartA.Strikeout.pdf DWC Petition for Suspension or Revocation of a Medical Provider Network Form 9767.17.5 (PART A)
DWCForm9767.17.5PartB.Strikeout.pdf DWC Petition for Suspension or Revocation of a Medical Provider Network Form 9767.17.5 (PART B)
AdjustingLocations.pdf 2016 Annual Report of Adjusting Locations
AuditInventory.pdf 2017 Annual Report of Inventory for Claims Reported During Calendar Year (CY) 2016
DWC-AU-905.pdf How to File a Complaint with the Audit Unit
DWC-AU-906.pdf Audit Referral Form
DWC-RGS-1.pdf Petition for Permission to Negotiate a Section 3201.7 Labor-Management Agreement
FactSheet_A.pdf Answers to Your Questions about Utilization Review
FactSheet_A_SP.pdf Answers to Your Questions about Utilization Review (Spanish)
FactSheet_B.pdf Glossary of Workers' Compensation Terms for Injured Workers
FactSheet_B_SP.pdf Glossary of Workers' Compensation Terms for Injured Workers (Spanish)
FactSheet_c.pdf Answers to Your Questions about Temporary Disability Benefits
FactSheet_C_SP.pdf Answers to Your Questions about Temporary Disability Benefits (Spanish)
FactSheet_D.pdf Answers to Your Questions about Permanent Disability Benefits
FactSheet_D_SP.pdf Answers to Your Questions about Permanent Disability Benefits (Spanish)
FactSheet_E.pdf Answers to Your Questions about Qualified Medical Evaluators and Agreed Medical Evaluators
FactSheet_E_SP.pdf Answers to Your Questions about Qualified Medical Evaluators and Agreed Medical Evaluators (Spanish)
FactSheet_F.pdf Answers to Your Questions about the State's Uninsured Employers Benefits Trust Fund
FactSheet_F_SP.pdf Answers to Your Questions about the State's Uninsured Employers Benefits Trust Fund (Spanish)
notice-poster.pdf POSTER - Notice to Employees Poster Poster must be printed on legal size (8 1/2 x 14) paper. (English and Spanish)
TimeofHirePamphlet.pdf BROCHURE - Facts about Workers' Compensation (Time of Hire Pamphlet from CA DWC)
TimeofHirePamphlet_Spanish.pdf BROCHURE - Facts about Workers' Compensation(Time of Hire Pamphlet from CA DWC) (Spanish)
Facts_IW.pdf BROCHURE - Facts for Injured Workers
SIP-A4-100.pdf Application for Self Insurance Administrator's Examination
SIP-A4-1.pdf Application for a Private Entity Certificate of Consent to Self Insure
SIP-A4-2.pdf Application for a Public Entity Certificate of Consent to Self Insure
SIP-A3-A.pdf Private Affiliate Interim Application
SIP-A3-B.pdf Application for Permanent Certificate Of Consent To Self Insure for Interim Self Insurer
SIP-A4-50.pdf Application for a Certificate of Consent to Administer Workers' Compensation Self Insurance Claims
SIP-4.pdf Agreement of Assumption and Guarantee of Workers' Compensation Liabilities
SIP-4-3.pdf Application for a Certificate of Consent to Self Insure by a Group of Employers
SIP-A4-3M.pdf Application for an Affiliate Certificate of Consent
SIP-4-5.pdf Corporate Resolution Authorizing Application to the Director of Industrial Relations,State of California For a Certificate of Consent to Self Insure Workers' Compensation Liabilities
SIP-4-6.pdf Agreement of Assumption and Guarantee of Workers' Compensation Liabilities
SIPCorpResolution.pdf Corporate Resolution Authorizing Application
GAI_request.pdf Request for Interim Certificate for Group Member
SIPintcer.pdf Request for Interim Certificate
SIPinfo.pdf Information Bulletin: Approved Securities
SIPinfotrust.pdf Information Bulletin: Cash in Trust
SIPinfo1.pdf Information Bulletin: Letter of Credit
SIPinfo2.pdf Information Bulletin: Surety Bond