Dwc 45: Dwc45 – Fill Online, Printable, Fillable, Blank

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.

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• 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

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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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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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