DWC 45: Understanding Workers’ Compensation Forms and Processes

What are the main types of DWC forms. How to fill out and submit workers’ compensation forms. Which forms are most commonly used in workers’ compensation cases. What is the purpose of different DWC forms.

Overview of DWC Forms and Their Importance

The Division of Workers’ Compensation (DWC) in California provides a wide array of forms crucial for managing workers’ compensation claims and related processes. These forms serve as the backbone of the workers’ compensation system, facilitating communication between injured workers, employers, medical providers, and the DWC itself.

DWC forms are categorized into several groups based on their purpose and the parties involved. Some of the main categories include:

• Audit forms
• Complaint forms
• Court forms
• Disability Evaluation forms
• Employer forms
• Independent Bill Review forms
• Independent Medical Review forms
• Lien forms
• Medical forms
• Medical Provider Network forms
• Pre-designation forms
• Public Records forms
• QME/AME forms
• SIBTF/UEBTF forms
• Supplemental Job Displacement Benefits forms

Key DWC Forms for Injured Workers

For injured workers, understanding and correctly filling out certain forms is crucial to ensuring their rights are protected and benefits are received in a timely manner. Some of the most important forms for injured workers include:

DWC 1: Workers’ Compensation Claim Form

This is the primary form used to initiate a workers’ compensation claim. It’s available in multiple languages including Spanish, Chinese, Korean, Tagalog, and Vietnamese to ensure accessibility for all workers.

DWC-AD 10133.36: Physician’s Return-to-Work & Voucher Report

This form is used by physicians to report on an injured worker’s ability to return to work and potentially qualify for a Supplemental Job Displacement Benefits voucher.

Mileage Form

Injured workers can use this form to claim reimbursement for travel expenses related to medical appointments and evaluations. It’s important to note that there are different versions for travel before and after January 1, 2023.

Essential Forms for Employers and Insurers

Employers and insurance companies also have specific forms they must complete and submit as part of the workers’ compensation process. Some key forms include:

DWC 7: Notice to Employees – Injuries Caused by Work

This form must be posted by employers in a conspicuous location at the workplace. It informs employees of their rights and the steps to take if they are injured on the job.

WCAB 10: Answer to Application for Adjudication of Claim

When an injured worker files an Application for Adjudication of Claim, the employer or insurer must respond using this form.

WCAB 46: Petition to Terminate Liability for Temporary Disability Indemnity

This form is used by employers or insurers when they believe an injured worker’s temporary disability benefits should be terminated.

Medical Evaluation and Provider Forms

The workers’ compensation system relies heavily on medical evaluations and reports. Several forms facilitate this process:

QME 105: Request for QME Panel Under Labor Code Section 4062.1 – Unrepresented

This form is used to request a panel of Qualified Medical Evaluators (QMEs) for cases where the injured worker is not represented by an attorney.

QME 106: Request for QME Panel Under Labor Code Section 4062.2 – Represented

Similar to QME 105, but used when the injured worker has legal representation.

DWC 9767.16.5: Complaint Form: Medical Provider Network

This form allows individuals to file complaints about Medical Provider Networks (MPNs) within the workers’ compensation system.

Dispute Resolution and Legal Forms

When disputes arise in workers’ compensation cases, several forms come into play:

DWC-CA 10250.1: Declaration of Readiness to Proceed

This form is filed when a party is ready to have their case heard before a workers’ compensation judge.

DWC-CA 10214-a: Stipulations with Request for Award

Used when parties have reached an agreement on the terms of a workers’ compensation award.

DWC-CA 10214-d: Compromise and Release – Dependency Claim

This form is used to settle dependency claims in cases where a worker has died due to a work-related injury or illness.

Navigating the DWC Form Filing Process

Filing DWC forms correctly is crucial for the smooth processing of workers’ compensation claims. Here are some tips to ensure proper submission:

1. Download the latest version of the form from the official DWC website
2. Use fillable PDF forms when available for clearer entries
3. Ensure all required fields are completed accurately
4. Pay attention to any specific instructions provided for each form
5. Keep copies of all submitted forms for your records
6. Submit forms to the correct DWC office or entity as specified in the instructions

Are electronic submissions accepted for DWC forms? Many DWC forms can now be submitted electronically through the DWC’s online filing system, which can streamline the process and reduce paperwork. However, some forms may still require physical signatures or notarization, so it’s important to check the specific requirements for each form.

Common Challenges and Solutions in Form Submission

While DWC forms are designed to be straightforward, many users encounter challenges when filling them out. Here are some common issues and how to address them:

Incomplete Information

Ensure all required fields are filled out completely. Missing information can lead to delays or rejection of the form.

Incorrect Form Version

Always use the most current version of the form available on the DWC website. Outdated forms may not be accepted.

Signature Requirements

Pay close attention to signature requirements. Some forms may need physical signatures, while others accept electronic signatures.

Language Barriers

For non-English speakers, seek assistance from bilingual staff or use translated versions of forms when available.

Technical Issues with Fillable PDFs

If experiencing problems with fillable PDFs, try using a different PDF reader or downloading the form again.

How can you get help if you’re unsure about filling out a DWC form? The DWC offers several resources for assistance, including detailed instructions for each form, a helpline for general questions, and the option to schedule an appointment with a DWC Information and Assistance Officer for more complex issues.

The Role of DWC Forms in Workers’ Compensation Appeals

When disputes in workers’ compensation cases cannot be resolved through initial processes, they may proceed to appeals. Several DWC forms play crucial roles in the appeals process:

WCAB 1: Application for Adjudication of Claim

This form initiates the formal legal process for resolving disputes. It’s typically filed when informal negotiations have failed to resolve issues.

DWC-CA 10208.3: Declaration of Readiness to Proceed – Expedited Trial

Used when a party is ready for an expedited hearing, often in cases involving medical treatment disputes or other time-sensitive issues.

DWC-CA 10232.1: Document Cover Sheet

This form must accompany all documents filed with the Workers’ Compensation Appeals Board (WCAB), ensuring proper categorization and processing of submitted materials.

What is the timeline for filing appeals-related forms? Timelines can vary depending on the specific circumstances of the case and the type of appeal. Generally, there are strict deadlines for filing appeals, often within 20 to 25 days of a decision. It’s crucial to consult with a workers’ compensation attorney or the DWC Information and Assistance Unit for specific deadlines applicable to your case.

Impact of Recent Changes on DWC Forms and Processes

The workers’ compensation system is subject to ongoing changes and updates, which can affect the forms and processes involved. Recent developments include:

COVID-19 Related Adjustments

The pandemic led to temporary changes in filing procedures, including increased reliance on electronic submissions and virtual hearings.

Updates to Benefit Rates

Forms related to benefit calculations may be updated annually to reflect changes in maximum and minimum benefit rates.

New Forms for Emerging Issues

As new challenges arise in the workers’ compensation system, new forms may be introduced to address specific needs or streamline processes.

How often are DWC forms updated? While there’s no set schedule, forms are typically reviewed and updated as needed to reflect changes in laws, regulations, or procedures. It’s important to always use the most current version of a form, which can be found on the official DWC website.

Navigating the complex world of workers’ compensation forms can be challenging, but understanding the purpose and proper use of these documents is crucial for all parties involved in the workers’ compensation process. By staying informed about the latest forms and procedures, injured workers, employers, medical providers, and legal professionals can ensure smoother claim processing and dispute resolution within the California workers’ compensation system.

DWC Forms

1. DWC

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.

Fillable form instructions = Fillable Adobe Acrobat form – en español = Adobe Acrobat for = Word form

• Audit forms
• Complaint forms
• Court forms
• Disability Evaluation forms
• Employer forms
• Independent Bill Review forms




• Independent Medical Review forms
• Lien forms

• Medical forms
• Medical Provider Network forms
• Pre-designation forms
• Public Records forms
• QME/AME forms
• SIBTF/UEBTF forms
• Supplemental Job Displacement Benefits forms

Fillable form instructions – we recommend downloading forms to your desktop

Fillable form instructions = Fillable Adobe Acrobat form – en español = Adobe Acrobat for = Word form

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 Spanish – Chinese – Korean – Tagalog – Vietnamese	DWC 1
Supplemental job displacement non-transferable voucher * Injuries occurring on or after 1/1/13	DWC – AD 1033.32
Medical mileage expense form English/Spanish * For travel on or after 1/1/23 Mileage prior to 1/1/23	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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Complaint forms

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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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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 Body part codes list Lista de códigos de las partes del cuerpo	DWC-CA 10232.1
Proof of service
Document separator sheet Changes to document separator sheet Document titles list	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
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 See I&A guide 8 for more detailed instructions Verification form
Application for discrimination benefits pursuant to Labor Code section 132 – A See I&A guide 7 for more detailed instructions Verification form
Attorney Fee Disclosure Statement (Rev. 1/17) Declaración Sobre Cobro De Honorarios	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 See I&A guide 9 for more detailed instructions Verification form	DWC WCAB 49
Petition for reconsideration	DWC WCAB 45
Petition to reopen Note: A declaration of readiness to proceed must also be filed with this form. See I&A guide 11for more detailed instructions 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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Employer forms

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Independent Bill Review forms

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Independent Medical Review forms

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Application for Independent Medical Review	DWC IMR
Petition appealing administrative director’s independent medical review determination Verification form
Independent medical review application Spanish * 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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Medical forms

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Medical Provider Network forms

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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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Public records forms

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QME/AME forms

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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

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SIBTF/UEBTF forms

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Supplemental Job Displacement Benefits forms

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

March 2022

Dwc045 Form – Fill Out and Sign Printable PDF Template

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Schedule a BRC
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II. INJURED EMPLOYEE CLAIM INFORMATION
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People also ask

• How do you check if a business has workers compensation in California?

  The Workers’ Compensation Coverage Inquiry website is a free service provided by the WCIRB for anyone to use in order to identify an insurer that wrote a California workers’ compensation insurance policy for a specific employer on a specific date within the last five years.

• What is a DWC 3 wage statement Texas?

  A DWC-3 is an Employer’s Wage Statement form outlined by the Texas Department of Insurance, Division of Workers’ Compensation (DWC). Texas Mutual uses this form to determine the injured employee’s average weekly wage and calculate financial assistance for them or their beneficiary.

• What forms are required on a California workers comp policy?

  The following forms need to be completed and submitted to EMPLOYERS when a work-related injury occurs: 5020 Employers Report of Occupational Injury or Occupational Disease. … DWC-1 Workers Compensation Claim Form. … Covered Employee Notification of Rights Material (English and Spanish). … Wage Statement. … First Fill Form.

• What is DWC in medical terms?

  The Medical Unit is a unit within the state Division of Workers’ Compensation (DWC) that manages medical issues in workers’ compensation. The DWC Medical Unit oversees medical provider networks (MPNs), health care organizations (HCOs), utilization review and medical treatment guidelines.

• What is a Texas non subscriber?

  Non-subscribers are employers who do not have workers’ compensation insurance coverage. While a Texas employer may choose not to have coverage, they must still follow certain workers’ compensation requirements.

• What is the DWC-1 California?

  Workers’ Compensation Claim Form (DWC-1) & Notice of Potential Eligibility, Rev. 1/16. The form that injured workers, their dependents or agents use to file a claim for workers’ compensation benefits in California (LC 5401, CCR 10139.)

• What is a DWC005 form?

  DWC005, Employer Notice of No Coverage or Termination of Coverage. DWC020SI, Self-Insured Governmental Entity Coverage Information. Steps to electronically submit a form to the Division of Workers’ Compensation: Open the form: Google Chrome and Microsoft Edge.

• What does DWC 1 stand for?

  DWC-1 Workers Compensation Claim Form. This is the form you will complete and send to EMPLOYERS to initiate the claim process for your employee. This form must be completed and provided to EMPLOYERS within one working day from you becoming aware of a work-related injury or occupational disease.

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Flat sheet 0.45 Zn primer ICE p/f, price 0 rubles per square meter

Flat sheet 0.45 Zn primer ICE p/f

Product description

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With Grand Line online store

simple –

• 
  Accurate calculation
  

  In order to carry out a preliminary calculation, you can use calculators or order a calculation from the manager.

• Convenient Delivery

  We offer a wide range of ways to receive an order throughout Russia.

• On-line payment

  For your convenience, we offer several types of payment for orders: in offices, on the website by card or by bank account.

Reviews

We deliver to any point of the Russian Federation and the CIS. More

• all cities

• Kazan

• Naberezhnye Chelny

Corporate offices

Payment

For your convenience, we provide several payment methods

online with a plastic card without commission
The operation is carried out by Sberbank of Russia

When ordering on the site, VISA, MasterCard, MIR and Maestro cards are accepted for payment, payment is made through the payment gateway of PJSC Sberbank of Russia.

To receive an order at pickup points, you will need to provide a secret code that will be sent via SMS to the phone number specified when placing the order.
For all types of delivery, the recipient of the order must present a passport. Please note that for courier delivery of an order paid for online, you must fill out an order receipt certificate, in which you need to indicate your passport data.

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For those near our retail stores

Pump NPW I-45 (Isuzu 8-97109-676-1)

• home

• Cooling

• Water pump

• org/ListItem”>

  ICE cooling pump water NPW I-45 – Isuzu Elf (GWIS-42A)

In stock: 1

NPW I45 (GWIS42A) – Isuzu Elf 4HF1 4HF1T Diesel (NKR NPR NPS NKS)

Complete with gasket

2

• Applicability
• OEM

Applicability

Packing information:

Alternate sources:

ISUZU	ELF	NKR66	4HF1	4300	90.05-
ISUZU	ELF	NPR66	4HF1	4300	90.05-
ISUZU	ELF	NKS66	4HF1	4300	93.12-
ISUZU	ELF	NPS66	4HF1	4300	93.12-95.04
ISUZU	ELF	VKR66	4HF1	4300	96.11-
ISUZU	ELF	NKR71	4HG1	4600	95.04-
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