LexisNexis® Automated Forms

$399.00LexisNexis® Automated California Workers' Compensation Forms

CALIFORNIA WORKERS’ COMPENSATION FORMS
The most comprehensive source for accessing electronically automated Workers’ Compensation Forms. The package includes official forms issued by the State of California’s Division of Workers’ Compensation, the Workers’ Compensation Appeals Board and the Industrial Medical Council.

The California Workers’ Compensation Forms package is comprehensive, intuitive, reliable, and easy to use. The repetitive typing, cutting, and pasting, and the increased chance of error that plague traditional methods of document preparation all disappear with HotDocs® document-assembly software. Simply enter case- or client-specific information once and HotDocs® will insert it where relevant throughout the form. You’ll produce a signature-ready document in minutes. You can also save the information you’ve entered and use the saved answers to complete related forms instantly.

Free Training included.

LexisNexis Workers’ Compensation Forms are 100% compliant with the now required EAMS system (Electronic Adjudication Management System).



  • To purchase this entire package, click on the " Purchase Package " button above. To ensure that you are always using the latest versions of the forms, any forms downloaded onto your computer will expire after 48 hours, but you may return to LexisOne at any time to download them again. Forms that you have already filled out and saved as separate documents will not expire. For questions about the two-day expiration policy, please call 1-877-507-6063, option 2.
     
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Best Value Forms You will need to log-in to purchase any of these forms


  • Arbitration Submittal Form (DWC-CA Form 10297) (Rev. November 17th 2008)
  • Arbitration Submittal Orders (WCAB 33) (New February 1991)
  • Arbitrator Application (March 18, 2009)

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  • Complaint about a Workers' Compensation Administrative Law Judge (WCU 39)
  • Fee Disclosure Statement (DWC 3) (Rev. March 1993)
  • Fee Disclosure Statement (Spanish version) (DWC 3) (Rev. March 1993)
  • Fee Disclosure Statement/Employee Consent to Venue/Declaration in Compliance (WCU-11)
  • Notice of Dismissal of Attorney (DIA WCAB 37) (Rev. August 1990)
  • Order Allowing Attorney's Fees (Rehabilitation Proceedings) (WCAB 53n)
  • Order Allowing Vocational Rehabilitation Attorney's Fees (WCU 23)
  • Petition for Increase in Attorney's Fees (WCU 24)
  • Petition for Order Allowing Pre-Application Attorney Fee and Order (WCAB 31) (Rev. February 1991)
  • Petition for Vocational Rehabilitation Attorney's Fees (WCU 22)
  • Petition to Disqualify Assigned WCJ and Supporting Declaration (WCU 21)
  • Substitution of Attorneys (DIA WCAB 36) (Rev. October 1974)

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  • Audit Referral Form (DWC AU 906) (June 2013)
  • How to File a Complaint with the Audit Unit (DWC AU 905) (Rev. June 2013)

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  • Petition for Permission to Negotiate a Section 3201.7 Labor-Management Agreement (DWC RGS-1) (January 2004)

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  • Compromise and Release (DWC-CA Form 10214 (c)) (Rev. November 17th 2008)
  • Compromise and Release (Dependency Claim) (DWC-CA Form 10214 (d)) (Rev. November 17th 2008)
  • Compromise and Release (Disability Claim) (DWC WCAB 15) (1992) (Rev. 1992)
  • Declaration of Readiness to Proceed to Expedited Hearing (Trial) (LC §5502(b)) (DWC-CA Form 10252.1) (April 2014)
  • Information Guidelines for Submission of Settlement Documents
  • Instructions for Social Security Addendum (WCU 37) (January 2005)
  • Minutes of Hearing (WCAB Form 20) (December 2012, Includes Minutes of Hearing Addendum Form (WCAB 20.2) NOTE:This Form Replaced "Minutes of Hearing/Order/Order and Decision on Request for Continuance (DWC-CA 10245)" in January 2014.)
  • Order Approving Compromise and Release (DIA WCAB 65) (Rev. May 1975)
  • Order Approving Compromise and Release (Third Party Settlement) (DIA WCAB 67) (Rev. October 1974)
  • Request for Accommodations by Persons with Disabilities (DWC Form 5) (Rev. January 2013)
  • Social Security Addendum (WCU 37) (January 2005)
  • Supplement to Minutes (WCAB Form 20.1) (Revised 2013)
  • Third Party Compromise and Release (DWC-CA 10214 (e)) (Rev. November 17th 2008)

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  • Petition for Commutation of Future Payments (DWC/WCAB 49) (November 1974)

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  • Order Dismissing Party Defendant (DWC WCAB 52) (Rev. March 1990)
  • Order Joining Party Defendant (DIA WCAB 53) (Rev. February 1975)
  • Order of Dismissal (DIA WCAB 51) (Rev. December 1975)
  • Petition to Join the Uninsured Employers Fund as a Party Defendant (WCU 20)
  • Request for Dismissal (DWC WCAB 43) (Rev. March 1990)

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  • Answers to Your Questions About Utilization Review (DWC Fact Sheet A) (March 2014)
  • Fact Sheet (July 2010)
  • Glossary of Workers' Compensation Terms for Injured Workers (DWC Fact Sheet B) (March 2013)
  • Answers to Your Questions About Temporary Disability Benefits (DWC Fact Sheet C) (March 2013)
  • Answers to Your Questions About Permanent Disability Benefits (DWC Fact Sheet D) (March 2013)
  • Answers to Your Questions About Qualified Medical Evaluators (DWC Fact Sheet E) (March 2013)
  • Answers to Your Questions About the State's Uninsured Employers Fund (DWC Fact Sheet F) (March 2013)

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  • Answer to Application for Adjudication of Claim (DWC/WCAB Form 10) (Rev. November 17th 2008)
  • Application for Adjudication of Claim (WCAB 1A) (Rev. November 17th 2008)
  • Application for Discretionary Payments From the Uninsured Employers' Fund (DWC/UEF 50) (Rev. November 17th 2008)
  • Application for Subsequent Injuries Fund Benefits (Rev. November 17th 2008)
  • Arbitration Submittal Form (DWC-CA Form 10297) (Rev. November 17th 2008)
  • Compromise and Release (DWC-CA Form 10214 (c)) (Rev. November 17th 2008)
  • Compromise and Release (Dependency Claim) (DWC-CA Form 10214 (d)) (Rev. November 17th 2008)
  • Cover Sheet (DWC-CA Form 10232.1) (Use to submit form sets using the EAMS Scanner OCR System. (Rev. July, 2010))
  • Cover Sheet (Form 10232.1), with attached Separator Sheet (Form 10232.2) (Cover Sheet (DWC-CA Form 10232.1) with a copy of the Document Separator Sheet (DWC-CA Form 10232.2) automatically inserted. (Rev. April 2014))
  • Declaration of Readiness to Proceed (DWC-CA Form 10250.1) (Rev. June 2011)
  • Declaration of Readiness to Proceed to Expedited Hearing (Trial) (LC §5502(b)) (DWC-CA Form 10252.1) (April 2014)
  • Document Separator Sheet (DWC-CA Form 10232.2) (Used to submit each form using EAMS Scanner OCR System. April 2014)
  • Employee's Permanent Disability Questionnaire (DEU 100) (Rev. November 17th 2008)
  • Minutes of Hearing (WCAB Form 20) (December 2012, Includes Minutes of Hearing Addendum Form (WCAB 20.2) NOTE:This Form Replaced "Minutes of Hearing/Order/Order and Decision on Request for Continuance (DWC-CA 10245)" in January 2014.)
  • Notice and Request for Allowance of Lien ((EAMS Form 2581) "EAMS (Golden-Rod Lien Form) Form 2581-(Rev. June 2008)")
  • Notice and Request for Allowance of Lien (DWC WCAB 6) (Rev. November 17th 2008)
  • Notice of Offer of Modified or Alternative Work (DWC-AD 10133.53)(SJDB) (For Injuries Occurring Between 1/1/2004 and 12/31/2012 Inclusive (Rev. January 1, 2014))
  • Notice of Offer of Regular Work (DWC-AD 10118) (SJDB) (For Injuries Occurring Between 1/1/05 - 12/31/12, Inclusive. (Rev. January 1, 2014))
  • Petition to Terminate Liability for Temporary Disability Indemnity (DIA WCAB 46) (Rev. November 17th 2008)
  • Pre-Trial Conference Statement (DWC-CA Form 10253.1)
  • Pre-Trial Conference Statement (Multiple Parties) (DWC-CA Form 10253.1) (Last Page)
  • Request for Consultative Rating (RCR) (DWC-AD form 104 (DEU)) (Rev. November 17th 2008)
  • Request for Dispute Resolution Before the Administrative Director (DWC-AD 10133.55)(SJDB) (Rev. January 1, 2014)
  • Request for Reconsideration of Summary Rating by the Administrative Director (DWC-AD Form 103 (DEU)) (Rev. November 17th 2008)
  • Request for Reimbursement of Accommodation Expenses (DWC-AD 10120)(SJDB) ("For injuries on or after July 1, 2004" (Rev. November 17th 2008))
  • Request for Summary Rating Determination of Primary Treating Physician's RPT (DWC-AD Form 102 (DEU)) (Rev. November 17th 2008)
  • Request for Summary Rating Determination of Qualified Medical Examiner's RPT (DWC-AD Form 101 (DEU)) (Rev. November 17th 2008)
  • Stipulations with Request for Award (Death Case) (DWC-CA Form 10214 (b)) (Rev. November 17th 2008)
  • Stipulations with Request for Award (Disability Case) (DWC-CA Form 10214 (a)) (November 2008)
  • Supplemental Job Displacement Nontransferable Training Voucher (DWC-AD 10133.57)(SJDB) (For Injuries Occurring Between 1/1/2004 and 12/31/2012 Inclusive (Rev. January 1, 2014))
  • Third Party Compromise and Release (DWC-CA 10214 (e)) (Rev. November 17th 2008)

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  • EDEX Client Acknowledgment of Legal Constraints on Access to Information and Use of Information (Rev. June 2006)
  • EDEX Client List (Rev. June 2006)
  • EDEX Subscriber Agreement (Rev. June 2006)

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  • Answer to Petition for Penalties and Points and Authorities in Support (WCU 26) (Rev. December 2005)
  • Notice of Intent to Seek Multiple Penalties (WCU 12) (Originally published January 2001) (Caution: SB 899 litigation still pending in courts)
  • Petition for Penalties (WCU 13) (Rev. September 2005) (CAUTION: SB 899 litigation still pending in courts)

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  • Report of Suspected Medical Care Provider Fraud (DWC SMBFR 1115) (Rev. March 2006)
  • Suspected Fraudulent Claim (CDI FB 1) (Rev. August 1994)

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  • Petition for Appointment of Guardian ad Litem and Trustee (DWC WCAB 8) (Rev. October 1990)

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  • HCO Enrollment Form (DWC 1194) (Rev. January 2003)

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  • Declaration of Defendant Re: Resolution of Liens (WCU 2) (Rev. October 1990)
  • Notice and Request for Allowance of Lien (DWC WCAB 6) (Rev. November 17th 2008)
  • Stipulation and Order to Pay Lien Claimant (WCU 3) (Valid February 1991)

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  • AME or QME Declaration of Service of Medical - Legal Report (QME Form 122) (Rev. February 2009)
  • Additional Panel Request (QME 31.7) (October 2013)
  • Application for Accreditation or Re-Accreditation as Education Provider (QME Form 118) (Rev. February 2009)
  • Application for Accreditation or Re-Accreditation as Education Provider-(QME Form 118 Instructions) (Rev. February 2009)
  • Application for Appointment as Qualified Medical Evaluator (QME Form 100) (October 2013)
  • Application for Independent Medical Review (DWC form IMR) (February 2014)
  • Course Evaluation for Administrative Director (QME Form 117) (October 2013)
  • Declaration Regarding Protection of Mental Health Record (QME Form 121) (Rev. February 2009)
  • Faculty Disclosure of Commercial Interest (QME Form 119) (Rev. February 2009)
  • How to Request a Qualified Medical Evaluator If You Do Not Have an Attorney (Attachment to Form 105) (Rev. February 2009)
  • How to Request a Qualified Medical Evaluator In a Represented Case (Attachment to Form 106) (Rev. February 2009)
  • Independent Medical Review Application (DWC 9768.10) (Rev. May 2007)
  • Medical Unit Request for QME Panel Under Labor Code § 4062.1 Unrepresented (QME Form 105) (October 2013)
  • Medical Unit Request for QME Panel Under Labor Code § 4062.2 Represented (QME Form 106) (October 2013)
  • Notice of Qualified Medical Evaluator Unavailability (IMC Form 109) (QME Form 109 (Rev. February 2009))
  • Official Medical Fee Schedule Order Form (GS 2055) (New March 2004)
  • Physician Contract Application (Independent Medical Reviewer) (DWC 9768.5) (Rev. May 2007)
  • Provider?s Request for Second Bill Review (DWC Form SBR-1) (February 2014)
  • QME Disclosure of Specified Financial Interests (QME Form 124) (Rev. February 2009)
  • QME or AME Conflict of Interest Disclosure Form and Objection or Waiver (QME Form 123) (Rev. February 2009)
  • QME or AME Conflict of Interest Disclosure Form and Objection or Waiver - (QME Form 123 Instructions) (Rev. February 2009)
  • QME/AME Time Frame Extension Report (QME Form 112) (October 2013)
  • Qualified Medical Evaluator Appointment Notification Form (QME Form 110) (October 2013)
  • Qualified Medical Evaluator Complaint Form (AD Form 1) (December 2008)
  • Qualified Medical Evaluator Exam Packet (Notice of QME Competency Examination October 18, 2014 Note: This packet includes suggested references for physicians planning to take the October 18th, 2014 QME Examination. Also included is an automated version of QME Form 102 (Revised 2/2009).)
  • Qualified Medical Evaluator Fees (IMC Form 103) (February 2009)
  • Qualified Medical Evaluator Letter (IMC Form 108) (Rev. April 2000)
  • Qualified or Agreed Medical Evaluator's Findings Summary (IMC Form 111) (QME Form 111 (Rev.February 2009))
  • Reappointment Application as Qualified Medical Evaluator (IMC Form 104) (QME Form 104 (Rev. February 2009))
  • Registration for QME Competency Examination (QME Form 102) (QME Form 102 (Rev. February 2009))
  • Replacement Panel Request (QME 31.5) (October 2013)
  • Request for Authorization for Medical Treatment (DWC Form RFA) (February 2014)
  • Request for Factual Correction of an Unrepresented Panel QME Report (QME Form 37) (October 2013)
  • Request for Independent Bill Review (DWC Form IBR-1) (February 2014)
  • Voluntary Directive for Alternate Service of Medical-Legal Evaluation Report on Disputed Injury to Psyche (QME Form 120) (Rev. February 2009)

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  • Cover Page for Medical Provider Network Application (DWC 9767.4) (Rev. May 2007)
  • Notice of Medical Provider Network Plan Modification (DWC 9767.8) (June 2010)
  • Sample Initial Written Employee Notification Letter (June 2007)
  • Sample Initial Written Employee Notification Letter (Spanish) (June 2007)
  • Sample Initial Written Employee Notification Re: Medical Provider Network (English) (Rev. June 2007)
  • Sample Initial Written Employee Notification Re: Medical Provider Network (Spanish) (Rev. June 2007)

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  • Notices Regarding Temporary Disability and Salary Continuation Benefits (Instructions to Claim Adjuster) - 8 CCR ? 9812(a) and ? 9814 (Effective 4-9-2008)
  • Notice Regarding Temporary Disability Benefits - Payment Start / Resume (Effective 4-9-2008))
  • Notice Regarding Temporary Disability Benefits - Delay (Effective 4-9-2008))
  • Notice Regarding Temporary Disability Benefits - Denial (Effective 4-9-2008)
  • Notice Regarding Temporary Disability Benefits - Payment Termination (Effective 4-9-2008)

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  • Indemnity Notices - Resumption, Change, Termination -- 8 CCR § 9812(b), (c), (d) (Instructions to Claim Adjuster) (Effective 4-9-2008)
  • Notice Regarding Indemnity Benefits - Payment / Resume (Effective 4-9-2008)
  • Notice Regarding Indemnity Benefits - Payment / Change (Effective 4-9-2008)
  • Notice Regarding Indemnity Benefits - Payment / Termination (Effective 4-9-2008)

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  • Notices Regarding Permanent Disability Benefits - 8 CCR § 9812(e) through (g) (Instructions to Claim Adjuster) (Effective 4-9-2008)
  • Notice Regarding Permanent Disability Benefits - Monitor for Disability Status (Effective 4-9-2008)
  • Notice Regarding Permanent Disability Benefits - Permanent Disability Advance (Effective 4-9-2008)
  • Notice Regarding Permanent Disability Benefits - Denial (Effective 4-9-2008)
  • Notice Regarding Permanent Disability Benefits - Payment Start / Resume (Effective 4-9-2008)

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  • Notice of Denial of Claim for Workers' Compensation Benefits - 8 CCR § 9812(i) (Instructions to Claim Adjuster) (Effective 4-9-2008)
  • Notice Regarding Denial of Workers' Compensation Benefit (Effective 4-9-2008)
  • Notice Regarding Delay of Workers' Compensation Benefit (Effective 4-9-2008)

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  • Notices Regarding Workers' Compensation Dependency Benefits - Title 8, CCR § 9812(h)(1) through (h)(4) (Instructions to Claim Adjuster) (Effective 4-9-2008)
  • Notice Regarding Dependency Benefits - First Payment (Effective 4-9-2008)
  • Notice Regarding Dependency Benefits - Change in Payment (Effective 4-9-2008)
  • Notice Regarding Dependency Benefits - Payment Termination (Effective 4-9-2008)
  • Notice Regarding Dependency Benefits - Delay (Effective 4-9-2008)
  • Notice Regarding Dependency Benefits - Denial (Effective 4-9-2008)

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  • AMA Guides--Checklists for Compliance of Medical Report on Spinal Injuries (Rev. February 2006)
  • AMA Guides--Common Acronyms (Rev. February 2006)
  • AMA Guides--Frequently Used Terms (Rev. February 2006)
  • Apportionment Referral (DEU 105) (Rev. June 2005)
  • Apportionment--Medical Questions on Pathology (Rev. February 2006)
  • Employee's Permanent Disability Questionnaire (DEU 100) (Rev. November 17th 2008)
  • Employee's Request for Informal Permanent Disability Rating (DEU 200) (Rev.February 1986)
  • Notice of Objection to Recommended Rating Instruction and Request for Cross Examination (WCU 36) (Notice of Objection to Recommended Rating Instruction and Request for Cross Examination of Disability Evaluation; Notice of Motion to Strike the Rating Instruction)
  • Notice of Options Following Permanent Disability Rating (DEU 110) (Rev. June 2005)
  • Request for Consultative Rating (RCR) (DWC-AD form 104 (DEU)) (Rev. November 17th 2008)
  • Request for Informal Rating (DEU 201) (by Insurance Carrier or Self-Insurer) (Rev. August 1990)
  • Request for Informal Rating (DIA 201) (by Insurance Carrier or Self-Insurer)
    (Rev. March 1986)
  • Request for Reconsideration of Summary Rating by the Administrative Director (DWC-AD Form 103 (DEU)) (Rev. November 17th 2008)
  • Request for Summary Rating Determination of Primary Treating Physician's RPT (DWC-AD Form 102 (DEU)) (Rev. November 17th 2008)
  • Request for Summary Rating Determination of Qualified Medical Examiner's RPT (DWC-AD Form 101 (DEU)) (Rev. November 17th 2008)

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  • Addendum to Application for Adjudication of Claim to Identify Legal Entity Employing Injure (WCAB 2) (August 2011)
  • Addendum to the Application and/or Answer (WCU 4) (Rev. February 1995)
  • Answer (Injuries Occurring before January 1, 1990 and on or after January 1, 1994) (DIA WCAB 10) (Rev. July 1981)
  • Answer (Injuries Occurring on or after January 1, 1990 and before January 1, 1994) (WCAB 2) (Valid April 1990)
  • Application for Adjudication of Claim (Death Case) (DIA WCAB 2) (Injuries Occurring before January 1, 1990 and on or after January 1, 1994) (Rev. July 1981)
  • Application for Adjudication of Claim (WCAB 1) (Injuries Occurring on or after January 1, 1990 and before January 1, 1994) (Valid March 1990)
  • Application for Adjudication of Claim (WCAB 1A) (Rev. November 17th 2008)
  • Application for Adjudication of Claim (WCAB 1P) (Injuries Occurring before January 1, 1990 and on or after January 1, 1994)
  • Application for Benefits for Serious and Willful Misconduct of Employer (WCU 5) (Injuries Occurring before January 1, 1990 and on or after January 1, 1994) (Rev. July 1981)
  • Application for Benefits for Serious and Willful Misconduct of Employer (WCU 5) (Alternate Version) (Alternate Version)
  • Application for Discrimination Benefits Pursuant to Labor Code Section 132(A) (WCU 132A)
  • Application for Subsequent Injuries Fund Benefits (WCU 18)
  • For Changes Needed on Official Address Record (Form WCAB-001) (Please enter information on this page and place in file.)
  • Notice of Representation and Request for Special Notice (WCU 28)
  • Petition for Automatic Reassignment to Another Workers' Compensation Judge (WCU 29)
  • Petition for Reinstatement/Reimbursement of Lost Wages and Work Benefits (WCU 19)
  • Workers' Compensation Claim Form (DWC 1) and Notice of Potential Eligibility (Rev. June 2010)
  • Written Application for Assessment of Sanctions for Bad Faith Action (WCU 34)

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  • Finding Order (Additional Panel QME-Unrepresented) (2014 (Proof of Service By Mail))
  • Order Additional Panel QME-Represented (2014 (Proof of Service By Mail))
  • Proof of Service by Mail (WCU 10)
  • Replacement Panel Represented (2014 (Proof of Service By Mail))
  • Unrepresented Replacement Panel (2014 (Proof of Service By Mail))
  • Verification (446, 2015.5 C.C.P.) (Rev. March 2009)
  • Verification (446, 2015.5 C.C.P.) With Proof of Service (Word Processor Forms) (Rev. March 2009)
  • Verification (446, 2015.5 C.C.P.) with Proof of Service (Rev. March 2009)

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  • Petition for Reconsideration (DIA WCAB 45) (April 2014)

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  • Petition to Reopen (DIA WCAB 42) (Rev. August 1985)

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  • Application for Spinal Surgery 2nd Opinion Physician List (DWC 232) (Rev. May 2007)
  • Designaci?n Previa de M?dico Particular (DWC 9783) (Spanish) (July 2014 (Spanish))
  • Doctor's First Report of Occupational Injury or Illness (DSLR 5021) (Rev. April 1992)
  • Employer's Notice of Employee Death (DIA 510) (Valid September 1984)
  • Employer's Report of Occupational Injury or Illness (Form 5020) (June 2002)
  • Medical Mileage Expense Form (Blank Form) (for travel after January 1, 2013) ((Rev. April 2013) (Blank version of the Mileage Expense Form without automation or computations).)
  • Medical Mileage Expense Form (for travel after January 1, 2013) (April 2013)
  • Medical Mileage Expense Form (for travel before July 1, 2006) (Rev. July 2005)
  • Medical Mileage Expense Form (for travel between January 1, 2007 and December 31, 2007) (April 2013)
  • Medical Mileage Expense Form (for travel between January 1, 2008 and June 30, 2008) (April 2013)
  • Medical Mileage Expense Form (for travel between January 1, 2009 and December 31, 2009) (April 2013)
  • Medical Mileage Expense Form (for travel between January 1, 2010 and December 31, 2010) (April 2013)
  • Medical Mileage Expense Form (for travel between January 1, 2011 and June 30, 2011) (April 2013)
  • Medical Mileage Expense Form (for travel between July 1, 2006 and December 31, 2006) (April 2013)
  • Medical Mileage Expense Form (for travel between July 1, 2008 and December 31, 2008) (April 2013)
  • Medical Mileage Expense Form (for travel between July 1, 2011 and December 31, 2012) (April 2013)
  • Notice of Personal Chiropractor or Personal Acupuncturist (DWC 9783.1) (July 2014)
  • Notice to Employees Poster (Notice to Employees -- Injuries Caused by Work (English and Spanish) (DWC 7) (Rev. June 2010))
  • Noticia de Quiropr?ctico Personal o Acupuntor Personal (DWC 9783.1) (Spanish) (July 2014 (Spanish))
  • Objection to Treating Doctor's Report (WCU 33)
  • Objection to Treating Physician's Recommendations for Spinal Surgery (DWC 233) (Rev. May 2007)
  • Petition for Change of Primary Treating Physician (DWC 280A) (Valid January 2001)
  • Physicians Guide Order Form (The Physician?s Guide to Medical Practice in the California Workers? Compensation System (3RD Edition, printed 12/01))
  • Predesignation of Personal Physician (DWC 9783) (July 2014)
  • Primary Treating Physician's Permanent and Stationary Report (DWC PR 3) (Rev. June 2005)
  • Primary Treating Physician's Permanent and Stationary Report (DWC PR 4) (Rev. June 2005)
  • Primary Treating Physician's Progress Report (DWC PR 2) (Rev. June 2005)
  • Response to Petition for Change of Primary Treating Physician (DWC 280B) (Valid January 2001)
  • Treating Physician's Determination of Medical Issues (IMC 81556) (Valid April 1995)

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  • Declaration of Readiness to Proceed (DWC-CA Form 10250.1) (Rev. June 2011)
  • Declaration of Readiness to Proceed to Expedited Hearing (Trial) (LC §5502(b)) (DWC-CA Form 10252.1) (April 2014)
  • Objection to Declaration of Readiness to Proceed (WCU 32)
  • Pre-Trial Conference Statement (DWC-CA Form 10253.1)
  • Pre-Trial Conference Statement (DWC-CA Form 10253.1)
  • Pre-Trial Conference Statement (Multiple Parties) (DWC-CA Form 10253.1) (Last Page)
  • Request for Accommodations by Persons with Disabilities (DWC Form 5) (Rev. January 2013)

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  • Stipulation and Award and/or Order (DWC WCAB 5) (New October 2005)
  • Stipulations with Request for Award (Death Case) (DWC-CA Form 10214 (b)) (Rev. November 17th 2008)
  • Stipulations with Request for Award (Disability Case) (DWC-CA Form 10214 (a)) (November 2008)
  • Stipulations with Request for Award (Disability Case) (DWC-WCAB Form 10214 (a)-1) (April 2014)

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  • Application for Issuance of Discovery Order (WCU 27)
  • Letter to Copy Service Regarding Motion to Quash Subpoena Duces Tecum (WCU 17)
  • Letter to Physician Regarding Motion to Quash Subpoena Duces Tecum (WCU 16)
  • Motion to Quash Subpoena Duces Tecum (WCU 14)
  • Notice of Taking Deposition by Oral Examination (WCU 30)
  • Notice to Appear at Hearing and Produce Documents (WCU 31)
  • Order Limiting Motion to Quash Subpoena Duces Tecum (WCU 15)
  • Petition for Pre-Application Discovery Order (WCAB 30) (Rev. February 1991)
  • Subpoena (DIA WCAB 30) (Rev. June 1994) (Judges signature files updated and valid as of December 2013)
  • Subpoena Duces Tecum (DIA WCAB 32) (Rev. June 1994) (Judges signature files updated and valid as of December 2013)

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  • Description of Employee's Job Duties (DWC-AD 10133.33) (SJDB) (Effective: January 1, 2014)
  • Mandatory Notices for Vocational Training and Return to Work (Instructions) (Effective 4-9-2008)
  • Notice of Offer of Modified or Alternative Work (DWC-AD 10133.35)(SJDB) (For injuries occurring on or after January 1, 2013 (Effective: January 1, 2014))
  • Notice of Offer of Modified or Alternative Work (DWC-AD 10133.53)(SJDB) (For Injuries Occurring Between 1/1/2004 and 12/31/2012 Inclusive (Rev. January 1, 2014))
  • Notice of Offer of Regular Work (DWC-AD 10118) (SJDB) (For Injuries Occurring Between 1/1/05 - 12/31/12, Inclusive. (Rev. January 1, 2014))
  • Notice of Potential Right to Supplemental Job Displacement Benefit Form (Effective 4-9-2008)
  • Noticia de Oferta de Trabajo Modificado o Alternativo (DWC-AD 10133.53) (Spanish) (injuries occurring on or after 1/1/04) (Spanish) (Rev. August 2006)
  • Noticia de Oferta de Trabajo Regular (DWC-AD 10003) (Spanish) (For injuries occurring on or after 1/1/05) (Spanish) (September 2006))
  • Physician's Report of Permanent and Stationary Status and Work Capacity (DWC - AD 10133.36) (SJDB) (For injuries occurring on or after January 1, 2013 (Effective: January 1, 2014))
  • Request for Dispute Resolution Before the Administrative Director (DWC-AD 10133.55)(SJDB) (Rev. January 1, 2014)
  • Request for Reimbursement of Accommodation Expenses (DWC-AD 10120)(SJDB) ("For injuries on or after July 1, 2004" (Rev. November 17th 2008))
  • Supplemental Job Displacement Non-Transferable Voucher (DWC-AD 10133.32) (For injuries occurring on or after January 1, 2013 (Effective: January 1, 2014))
  • Supplemental Job Displacement Nontransferable Training Voucher (DWC-AD 10133.57)(SJDB) (For Injuries Occurring Between 1/1/2004 and 12/31/2012 Inclusive (Rev. January 1, 2014))

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  • Petition to Terminate Liability for Temporary Disability Indemnity (DIA WCAB 46) (Rev. November 17th 2008)

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  • Complaint for Compensatory Damages by Injured Employee Against Negligent... (577-522)
  • Complaint for Compensatory and Punitive Damages by Injured Employee... (577-525)
  • Complaint for Compensatory and Punitive Damages by Injured Employee/Employer (577-524)
  • Complaint for Damages or in Intervention - By Insurance Against Third-Party (577-520) (Complaint for Damages or in Intervention - By Insurance Carrier Against Third-Party Tortfeasor)
  • Employer's Affirmative Defense-Employee's Action Barred by Exclusive Remedy... (577-530)
  • Employer's Affirmative Defense-Lack of Jurisdiction Due to Pending Workers...(577-531)
  • Employer's Affirmative Defense-Negligence of Plaintiff (577-532)
  • Notice of Filing of Complaint Against Third Party - By Employee or Employer (577-021)
  • Petition for Credit of Third-Party Judgment Against Compensation Liability (577-542)
  • Proceedings to Secure Lien Against Third-Party Judgment-Notice of Motion and Supporting Declaration (577-540)
  • Proceedings to Secure Lien Against Third-Party Judgment-Order Granting Motion (577-541)

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  • Special Notice of Lawsuit (WCU 7)

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  • Utilization Review (UR) Complaint Form (DWC UR 1) (April 2014)

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  • Appeal from Determination and Order of the Rehabilitation Unit (WCU 35) (Alternate Version)
  • Appeal from the Determination (or Decision and Order) of the Rehab. Unit (WCU 35)
  • Case Initiation Document (DWC RU 101) (Valid December 1990)
  • Description of Employee's Job Duties (DWC RU 91) (Valid February 1995)
  • Employee Statement of Declination of Vocational Rehabilitation Services (DWC RU 107 A) (Valid January 1994)
  • Employee Statement of Declination of Vocational Rehabilitation Services (DWC RU 107) (December 2002)
  • Employee Statement of Declination of Vocational Rehabilitation Services (Spanish) (DWC RU 107) (December 2002)
  • Employee Statement of Declination of Vocational Rehabilitation Services (Spanish) (DWC RU 107A) (Valid January 1994) (Spanish)
  • Initial Evaluation Summary (DWC RU 120) (Rev. January 2003)
  • Notice of Offer of Modified or Alternate Work (DWC RU 94) (Valid January 2003)
  • Notice of Offer of Modified or Alternate Work (DWC RU 94) (Spanish) (Valid January 1994) (Spanish))
  • Request for Conclusion of Rehabilitation Benefits (DWC RB 105) (Valid January 2003)
  • Treating Physician's Report of Disability Status (DWC RU 90) (Valid December 1990)
  • Vocational Rehabilitation Progress Report (DWC RU 121) (Valid September 1998)

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  • Vocational Rehabilitation Notices - Title 8, CCR § 9813(a) through (d) (Instructions to Claims Adjuster) (Effective 4-9-2008)
  • Notice Regarding Vocational REHAB Benefits - VR Maintenance Allowance Start / Resume - VR Temporary Disability Start / Resume (Effective 4-9-2008)
  • Notice Regarding Vocational Rehabilitation Benefits - Potential Eligibility and Delay (Effective 4-9-2008)
  • Notice Regarding Vocational Rehabilitation Benefits - Potential Eligibility and Subsequent Delay (Effective 4-9-2008)
  • Notice Regarding Vocational Rehabilitation Benefits - Denial (Effective 4-9-2008)
  • Notice of Interruption or Deferral of Vocational Rehabilitation Services (Effective 4-9-2008)
  • Vocational Rehabilitation Reinstatement Request (Effective 4-9-2008)
  • Notice Regarding Vocational Rehabilitation Benefits - 90 Days of Total Disability (Effective 4-9-2008)
  • Notice Regarding Vocational Rehabilitation Benefits - Potential Eligibility (Effective 4-9-2008)
  • Notice Regarding Vocational Rehabilitation Benefits - Reminder of Potential Eligibility (Effective 4-9-2008)
  • Notice Regarding Vocational Rehabilitation Benefits - Intention to Withhold Maintenance Allowance for Failure to Cooperate (Effective 4-9-2008)
  • Vocational Rehabilitation Reply Form (Effective 4-9-2008)

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  • Request for Walk-Through Declarations of Readiness ONLY (cawc0001)
  • Request for Walk-Through Declarations of Readiness ONLY - Notice Waived Basis ONLY (cawc0003)
  • Request for Walk-Through Settlements, Attorneys' Fees, Petitions to Compel Attendance and Stay Order Request (cawc0002)

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  • File Request for WCAB Action--Walk Through (WCU 8) (Valid March 1996)
  • Public Records Act Request Form (WCU 38) (May 2011)
  • Request for DWC Authorization Number (DWC AD 3) (New May 2006)
  • Request for WCAB Case # Search (DWC AD 2) (Valid May 1993)
  • Request to View a WCAB Case File (DWC AD 1) (Valid May 1993)
  • WCAB Data Entry Sheet (WCU 9) (Valid May 1993)

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