DWC Forms
- 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.![]()
| 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 1033.32 |
Medical mileage expense form English/Spanish * For travel on or after 1/1/23
| Mileage form |
Additional QME panel request | QME 31.![]() |
Request For QME panel under Labor Code Section 4062.2 – Represented * injuries occurring prior to 1/1/05
| QME 106 |
Notice to Employees – Injuries caused by work
– English and Spanish | DWC 7 |
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Audit 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
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Complaint 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
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.![]() |
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Court 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
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.![]() |
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
Verification form
| |
Application for discrimination benefits pursuant to Labor Code section 132 – A
| |
Attorney Fee Disclosure Statement (Rev.
| 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
| 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
Fillable form instructions – we recommend downloading forms to your desktop
Fillable form instructions = Fillable Adobe Acrobat form – en español = Adobe Acrobat for = Word form
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Employer 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
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Independent Bill Review forms
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Fillable form instructions = Fillable Adobe Acrobat form – en español = Adobe Acrobat for = Word form
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Independent Medical Review 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
Application for Independent Medical Review | DWC IMR |
Petition appealing administrative director’s independent medical review determination
Verification form | |
Independent medical review application
*
| DWC 9768.![]() |
Physician contract application * For doctors who want to become independent medical reviewers | DWC 9768.5 |
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Lien 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
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Medical forms
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Fillable form instructions = Fillable Adobe Acrobat form – en español = Adobe Acrobat for = Word form
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Medical Provider Network 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
Cover page for medical provider network application or plan for reapproval | DWC 9767.![]() |
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
Fillable form instructions – we recommend downloading forms to your desktop
Fillable form instructions = Fillable Adobe Acrobat form – en español = Adobe Acrobat for = Word form
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Public records 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
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QME/AME 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
Additional QME panel request | QME 31.![]() |
AME or QME declaration of service of medical – legal report | QME 122 |
Application for accreditation or re-accreditation as education provider
| 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
| 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.![]() |
Request for Factual Correction of a Unrepresented Panel QME Report | QME 37 |
Request For QME panel under Labor Code Section 4062.1 – Unrepresented
| QME 105 |
Solicitud De Panel De Evalua dor Medicó Calificado- Empleado sin representación legal
| QME 105 |
Request For QME panel under Labor Code Section 4062.2 * For injuries occurring prior to 1/1/05 Represented
| 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
Fillable form instructions – we recommend downloading forms to your desktop
Fillable form instructions = Fillable Adobe Acrobat form – en español = Adobe Acrobat for = Word form
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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
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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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Your request:
2. Check applicable box(es) for services you are requesting:
Special Accommodations (Please specify)
____________________________________________
Schedule a BRC
Reschedule a BRC
Cancel a BRC
Expedited BRC (Provide reason)
____________________________________________
II. INJURED EMPLOYEE CLAIM INFORMATION
3. Employee’s Name (Last, First, Middle)
4. Employee’s Physical Address
5. Insurance Carrier’s Name
6. Date of Injury (mm-dd-yyyy)
8. Employer’s Business Name (at the…
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How to create an electronic signature for a PDF online
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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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