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LexisNexis® Automated California Workers' Compensation Forms

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ISBN: 9780820546650
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Access the most comprehensive source for 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. Since the forms are fully automated with HotDocs® document assembly software, all you have to do is enter case or client-specific information once, and it will be automatically inserted throughout the form where that information is relevant. This means you’ll be printing out signature-ready documents in minutes.

Eliminate repetitive typing, cutting and pasting, and the increased chance of error that goes along with traditional methods of document preparation. You can also save the information you’ve entered after completing a form and use it to instantly complete related forms.

100% compliant with EAMS Scanner Forms Program

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Purchase price includes free training.

Table of Contents

California Workers’ Compensation Forms

Defense Case Evaluation Checklist
Attorney and Court Interview
General Interview

Arbitration

Arbitration Submittal Form (DWC-CA Form 10297)
Arbitration Submittal Orders (WCAB 33)
Arbitrator Application

Attorneys and Judges

Complaint about a Workers’ Compensation Administrative Law Judge (WCU 39)
Fee Disclosure Statement (DWC 3)
Fee Disclosure Statement (DWC 3) (Spanish)
Fee Disclosure Statement/Employee Consent to Venue/Declaration in Compliance (WCU 11) (Word)
Fee Disclosure Statement/Employee Consent to Venue/Declaration in Compliance (WCU 11) (WordPerfect)
Notice of Dismissal of Attorney (DIA WCAB 37)
Order Allowing Attorney’s Fees (Rehabilitation Proceedings) (DIA WCAB 53n)
Order Allowing Vocational Rehabilitation Attorney’s Fees (WCU 23) (Word)
Order Allowing Vocational Rehabilitation Attorney’s Fees (WCU 23) (WordPerfect)
Petition for Increase in Attorney’s Fees (WCU 24) (Word)
Petition for Increase in Attorney’s Fees (WCU 24) (WordPerfect)
Petition for Order Allowing Pre-Application Attorney Fee and Order (WCAB 31)
Petition for Vocational Rehabilitation Attorney’s Fees (WCU 22) (Word)
Petition for Vocational Rehabilitation Attorney’s Fees (WCU 22) (WordPerfect)
Petition to Disqualify Assigned WCJ and Supporting Declaration (WCU 21) (Word)
Petition to Disqualify Assigned WCJ and Supporting Declaration (WCU 21) (WordPerfect)
Substitution of Attorney (DIA WCAB 36)

Audit

How to File a Complaint with the Audio Unit (DWC AU 905)
Audit Referral Form (DWC AU 906)

Carve Outs

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

Case Setting and Hearings

Declaration of Readiness to Proceed (DWC-CA Form 10250.1)
Declaration of Readiness to Proceed to Expedited Hearing (Trial) (LC §5502(b)) (DWC-CA Form 10252.1)
Minutes of Hearing/Order/Order and Decision on Request for Continuance (DWC-CA 10245)
Objection to Declaration of Readiness to Proceed (WCU 32) (Word)
Objection to Declaration of Readiness to Proceed (WCU 32) (WordPerfect)
Pre-Trial Conference Statement (Multiple Parties) (DWC-CA Form 10253.1)(Last Page)
Pre-Trial Conference Statement (DWC-CA Form 10253.1)
Request for Accommodations by Persons with Disabilities (DWC Form 5)

Commutations

Petition for Commutation of Future Payments (DIA WCAB 49)

Dismissal and Joinder

Order Dismissing Party Defendant (DWC WCAB 52)
Order Joining Party Defendant (DIA WCAB 53)
Order of Dismissal (DIA WCAB 51)
Petition to Join the Uninsured Employers Fund as a Party Defendant (WCU 20) (Word)
Petition to Join the Uninsured Employers Fund as a Party Defendant (WCU 20) (WordPerfect)
Request for Dismissal (DWC WCAB 43)

Division of Workers’ Compensation Fact Sheets

Answers to Your Questions About Utilization Review (DWC Fact Sheet A)
Answers to Your Questions About Utilization Review (DWC Fact Sheet A) (Spanish)
Answers to Your Questions About Utilization Review (DWC Fact Sheet A) (Word)
Answers to Your Questions About Utilization Review (DWC Fact Sheet A) (WordPerfect)
Glossary of Workers’ Compensation Terms for Injured Workers (DWC Fact Sheet B)
Glossary of Workers’ Compensation Terms for Injured Workers (DWC Fact Sheet B) (Spanish)
Glossary of Workers’ Compensation Terms for Injured Workers (DWC Fact Sheet B) (Word)
Glossary of Workers’ Compensation Terms for Injured Workers (DWC Fact Sheet B) (WordPerfect)
Answers to Your Questions About Temporary Disability Benefits (DWC Fact Sheet C)
Answers to Your Questions About Temporary Disability Benefits (DWC Fact Sheet C) (Spanish)
Answers to Your Questions About Temporary Disability Benefits (DWC Fact Sheet C) (Word)
Answers to Your Questions About Temporary Disability Benefits (DWC Fact Sheet C) (WordPerfect)
Answers to Your Questions About Permanent Disability Benefits (DWC Fact Sheet D)
Answers to Your Questions About Permanent Disability Benefits (DWC Fact Sheet D) (Spanish)
Answers to Your Questions About Permanent Disability Benefits (DWC Fact Sheet D) (Word)
Answers to Your Questions About Permanent Disability Benefits (DWC Fact Sheet D) (WordPerfect)
Answers to Your Questions About Qualified Medical Evaluators (DWC Fact Sheet E)
Answers to Your Questions About Qualified Medical Evaluators (DWC Fact Sheet E) (Spanish)
Answers to Your Questions About Qualified Medical Evaluators (DWC Fact Sheet E) (Word)
Answers to Your Questions About Qualified Medical Evaluators (DWC Fact Sheet E) (WordPerfect)
Answers to Your Questions About the State’s Uninsured Employers Fund (DWC Fact Sheet F)
Answers to Your Questions About the State’s Uninsured Employers Fund (DWC Fact Sheet F) (Spanish)
Answers to Your Questions About the State’s Uninsured Employers Fund (DWC Fact Sheet F) (Word)
Answers to Your Questions About the State’s Uninsured Employers Fund (DWC Fact Sheet F)(WordPerfect)

EAMS (Scanner OCR Forms)

EAMS-OCR Handbook of Instructions

Court Administrator Forms

Cover Sheet (DWC-CA Form 10232.1)
Cover Sheet (DWC-CA Form 10232.1) (Instruction Tables)
Document Separator Sheet (DWC-CA Form 10232.2)
Document Separator Sheet (DWC-CA Form 10232.2) (Document List)
Cover Sheet and Separator Sheet (combined)
Stipulations with Request for Award (Disability Case) (DWC-CA Form 10214 (a))
Stipulations with Request for Award (Death Case) (DWC-CA Form 10214 (b))
Compromise and Release (DWC-CA Form 10214 (c))
Compromise and Release (Dependency Claim) (DWC-CA Form 10214 (d))
Third Party Compromise and Release (DWC-CA 10214 (e))
Minutes of Hearing/Order/Order and Decision on Request for Continuance (DWC-CA 10245)
Declaration of Readiness to Proceed (DWC-CA Form 10250.1)
Declaration of Readiness to Proceed to Expedited Hearing (Trial) (LC §5502(b)) (DWC-CA Form 10252.1)
Pre-Trial Conference Statement (DWC-CA Form 10253.1)
Pre-Trial Conference Statement (Multiple Parties) (DWC-CA Form 10253.1)(Last Page)
Arbitration Submittal Form (DWC-CA Form 10297)

Disability Evaluation Unit (DEU) Forms

Employee’s Permanent Disability Questionnaire (DWC-AD Form 100 (DEU))
Request for Summary Rating Determination of Qualified Medical Examiner’s RPT (DWC-AD Form 101 (DEU))
Request for Summary Rating Determination of Primary Treating Physician’s RPT (DWC-AD Form 102 (DEU))
Request for Reconsideration of Summary Rating by the Administrative Director (DWC-AD Form 103 (DEU))
Request for Consultative Rating (RCR) (DWC-AD Form 104 (DEU))

Retraining and Return to Work Unit (RRTW) Forms

Vocational Rehabilitation Plan (Voc. Rehab. §10133.13) (RU 102)
Request for Dispute Resolution (Voc. Rehab. §10133.14) (RU 103)
Notice of Termination of Rehabilitation Services (Voc. Rehab. §10133.16) (RU 105)
Notice of Offer of Regular Work (DWC-AD 100118) (SJDB)
Request for Reimbursement of Accommodation Expenses (DWC-AD 10120)(SJDB)
Settlement of Prospective Vocational Rehabilitation Services [LC § 4646(b)] (RU 122)
Notice of Offer of Modified or Alternative Work (DWC-AD 10133.53)(SJDB)
Request for Dispute Resolution Before the Administrative Director (DWC-AD 10133.55)(SJDB)
Supplemental Job Displacement Nontransferable Training Voucher (DWC-AD 10133.57)(SJDB)

Uninsured Employers Benefits Trust Fund/Subsequent Injuries Benefits Trust Fund Forms

Application for Discretionary Payments From the Uninsured Employers’ Fund (DWC/UEF 50)
Application for Subsequent Injuries Fund Benefits

Workers’ Compensation Appeals Board Forms

Answer to Application for Adjudication of Claim (DWC/WCAB Form 10)
Application for Adjudication of Claim (DWC/WCAB Form 1A)
Notice and Request for Allowance of Lien (DWC/WCAB Form 6)
Petition to Terminate Liability for Temporary Disability Indemnity (DWC WCAB 46)

EDEX Administrative Forms

EDEX Client Acknowledgment of Legal Constraints on Access to Information and Use of Information
EDEX Client List
EDEX Subscriber Agreement

Enforcement of Awards

Notice of Intent to Seek Multiple Penalties (WCU 12) (Word)
Notice of Intent to Seek Multiple Penalties (WCU 12) (WordPerfect)
Petition for Penalties (WCU 13) (Word)
Petition for Penalties (WCU 13) (WordPerfect)
Answer to Petition for Penalties and Points and Authorities in Support (WCU 26) (Word)
Answer to Petition for Penalties and Points and Authorities in Support (WCU 26) (WordPerfect)

Fraud

Report of Suspected Medical Care Provider Fraud (DWC SMBFR 1115)
Suspected Fraudulent Claim (CDI FB 1)

Guardian Ad Litem

Petition for Appointment of Guardian ad Litem and Trustee (DWC WCAB 8)

Health Care Organizations

HCO Enrollment Form (DWC 1194)

Liens

Declaration of Defendant Re: Resolution of Liens (WCU 2)
Notice and Request for Allowance of Lien (DWC/WCAB Form 6)
Stipulation and Order to Pay Lien Claimant (WCU 3)

Medical Examinations

Qualified Medical Evaluator Complaint Form (AD Form 1)
Application for Appointment as Qualified Medical Evaluator (QME Form 100)
Qualified Medical Evaluator Exam Packet (QME 100)
Registration for QME Competency Examination (QME Form 102)
Qualified Medical Evaluator Fees (QME Form 103)
Reappointment Application as Qualified Medical Evaluator (QME Form 104)
Medical Unit Request for QME Panel Under Labor Code § 4062.1 Unrepresented
Medical Unit Request for QME Panel Under Labor Code § 4062.1 Unrepresented (Instructions)
Medical Unit Request for QME Panel Under Labor Code § 4062.2 Represented
Medical Unit Request for QME Panel Under Labor Code § 4062.2 Represented (Instructions)
Qualified Medical Evaluator Letter (QME Form 108)
Notice of Qualified Medical Evaluator Unavailability (QME Form 109)
Qualified Medical Evaluator Appointment Notification Form (QME Form 110)
Qualified or Agreed Medical Evaluator’s Findings Summary (QME Form 111)
QME/AME Time Frame Extension Report (QME Form 112)
Application for Accreditation or Re-Accreditation as Education Provider (QME Form 118)
Application for Accreditation or Re-Accreditation as Education Provider-(QME Form 118 Instructions)
Faculty Disclosure of Commercial Interest (QME Form 119)
Voluntary Directive for Alternate Service of Medical-Legal EVAL. Report on Disputed Injury to Psyche
Declaration Regarding Protection of Mental Health Record (QME Form 121)
AME or QME Declaration of Service of Medical – Legal Report (QME Form 122)
QME or AME Conflict of Interest Disclosure Form and Objection or Waiver (QME Form 123)
QME or AME Conflict of Interest Disclosure Form and Objection or Waiver-(QME Form 123 Instructions)
QME Disclosure of Specified Financial Interests (QME Form 124)
Physician Contract Application (Independent Medical Reviewer) (DWC 9768.5)
Independent Medical Review Application (DWC 9768.10)
Official Medical Fee Schedule Order Form (GS 2055)

Medical Provider Networks

Cover Page for Medical Provider Network Application (DWC 9767.4)
Notice of Medical Provider Network Plan Modification (DWC 9767.8)
Sample Initial Written Employee Notification Re: Medical Provider Network (English)
Sample Initial Written Employee Notification Re: Medical Provider Network (Spanish)

Model Benefit Notices Regarding Temporary Disability and Salary Continuation

Notices Regarding Temp Disability/Salary Continuation Benefits (Word) (Claims Adjuster Instructions)
Notices Regarding Temp Disability/Salary Continuation Benefits (WP) (Claims Adjuster Instructions)
Payment Start / Resume Temporary Disability (Word)
Payment Start / Resume Temporary Disability (WordPefect)
Delay Temporary Disability (Word)
Delay Temporary Disability (WordPerfect)
Denial Temporary Disability (Word)
Denial Temporary Disability (WordPerfect)
Payment Termination (Word)
Payment Termination (WordPerfect)

Model Benefit Notices Regarding Resumption, Change, Termination

Indemnity Notices – Resumption, Change, Termination (Word) (Claims Adjuster Instructions)
Indemnity Notices – Resumption, Change, Termination (WordPerfect) (Claims Adjuster Instructions)
Payment / Resume Temporary Disability (Word)
Payment / Resume Temporary Disability (WordPerfect)
Payment / Change Temporary Disability (Word)
Payment / Change Temporary Disability (WordPerfect)
Payment / Termination Temporary Disability (Word)
Payment / Termination Temporary Disability (WordPerfect)

Model Benefit Notices Regarding Permanent Disability

Notices Regarding Permanent Disability Benefits (Word) (Claims Adjuster Instructions)
Notices Regarding Permanent Disability Benefits (WordPerfect) (Claims Adjuster Instructions)
Monitor for Disability Status (Word)
Monitor for Disability Status (WordPerfect)
Permanent Disability Advance (Word)
Permanent Disability Advance (WordPerfect)
Denial Permanent Disability (Word)
Denial Permanent Disability (WordPerfect)
Payment Start / Resume Permanent Disability (Word)
Payment Start / Resume Permanent Disability (WordPerfect)

Model Benefit Notices Regarding Denial of Benefit and Delay of Benefit

Notice of Denial of Claim for Workers’ Compensation Benefits (Word) (Claims Adjuster Instructions)
Notice of Denial of Claim for Workers’ Compensation Benefits (WP) (Claims Adjuster Instructions)
Notice Regarding Denial of Workers’ Compensation Benefit (Word)
Notice Regarding Denial of Workers’ Compensation Benefit (WordPerfect)
Notice Regarding Delay of Workers’ Compensation Benefit (Word)
Notice Regarding Delay of Workers’ Compensation Benefit (WordPerfect)

Model Benefit Notices Regarding Dependency

Notices Regarding Workers’ Compensation Dependency Benefits (Word) (Claims Adjuster Instructions)
Notices Regarding Workers’ Compensation Dependency Benefits (WP) (Claims Adjuster Instructions)
Notice Regarding Dependency Benefits – First Payment (Word)
Notice Regarding Dependency Benefits – First Payment (WordPerfect)
Notice Regarding Dependency Benefits – Change in Payment (Word)
Notice Regarding Dependency Benefits – Change in Payment (WordPerfect)
Notice Regarding Dependency Benefits – Payment Termination (Word)
Notice Regarding Dependency Benefits – Payment Termination (WordPerfect)
Notice Regarding Dependency Benefits – Delay (Word)
Notice Regarding Dependency Benefits – Delay (WordPerfect)
Notice Regarding Dependency Benefits – Denial (Word)
Notice Regarding Dependency Benefits – Denial (WordPerfect)

Permanent Disability Ratings

AMA Guides--Apportionment--Medical Questions on Pathology
AMA Guides--Checklists for Compliance of Medical Report on Spinal Injuries
AMA Guides--Common Acronyms
AMA Guides--Frequently Used Terms
Employee’s Permanent Disability Questionnaire (DWC-AD Form 100 (DEU))
Request for Summary Rating Determination of Qualified Medical Examiner’s RPT (DWC-AD Form 101 (DEU))
Request for Summary Rating Determination of Primary Treating Physician’s RPT (DWC-AD Form 102 (DEU))
Request for Reconsideration of Summary Rating by the Administrative Director (DWC-AD Form 103 (DEU))
Request for Consultative Rating (RCR) (DWC-AD form 104 (DEU))
Apportionment Referral (DEU Form 105)
Notice of Options Following Permanent Disability Rating (DEU Form 110)
Employee’s Request for Informal Permanent Disability Rating (DIA 200)
Notice of Objection to Recommended Rating Instruction Request for Cross Exam. (WCU 36) (Word)
Notice of Objection to Recommended Rating Instruction Request for Cross Exam. (WCU 36) (WordPerfect)
Request for Informal Rating (DEU 201)
Request for Informal Rating (DIA 201)

Pleadings

For Changes Needed on Official Address Record (Form WCAB-001)
Addendum to the Application and/or Answer (WCU 4)
Answer (Injuries Occurring before January 1, 1990 and on or after January 1, 1994) (DIA WCAB 10)
Answer (Injuries Occurring on or after January 1, 1990 and before January 1, 1994) (WCAB 2)
Application for Adjudication of Claim (Death Case) (DIA WCAB 2)
Application for Adjudication of Claim (DWC/WCAB Form 1A)
Application for Adjudication of Claim (WCAB 1)
Application for Adjudication of Claim (WCAB 1P)
Application for Benefits for Serious and Willful Misconduct of Employer (WCU 5)
Application for Benefits for Serious and Willful Misconduct of Employer (WCU 5) (Alternate Version)
Application for Discrimination Benefits Pursuant to Labor Code Section 132(A) (WCU 132A)
Application for Subsequent Injuries Fund Benefits (WCU 18) (Word)
Application for Subsequent Injuries Fund Benefits (WCU 18) (WordPerfect)
Petition for Reinstatement/Reimbursement of Lost Wages and Work Benefits (WCU 19) (Word)
Petition for Reinstatement/Reimbursement of Lost Wages and Work Benefits (WCU 19) (WordPerfect)
Notice of Representation and Request for Special Notice (WCU 28) (Word)
Notice of Representation and Request for Special Notice (WCU 28) (WordPerfect)
Petition for Automatic Reassignment to Another Workers’ Compensation Judge (WCU 29) (Word)
Petition for Automatic Reassignment to Another Workers’ Compensation Judge (WCU 29) (WordPerfect)
Workers’ Compensation Claim Form (DWC 1) and Notice of Potential Eligibility
Written Application for Assessment of Sanctions for Bad Faith Action (WCU 34) (Word)
Written Application for Assessment of Sanctions for Bad Faith Action (WCU 34) (WordPerfect)

Proof of Service and Verification Forms

Proof of Service by Mail (WCU 10) (Word)
Proof of Service by Mail (WCU 10) (WordPerfect)
Verification (446, 2015.5 C.C.P.)
Verification (446, 2015.5 C.C.P.) with Proof of Service
Verification (446, 2015.5 C.C.P.) with Proof of Service (Word)
Verification (446, 2015.5 C.C.P.) with Proof of Service (WordPerfect)

Reconsideration

Petition for Reconsideration (DIA WCAB 45)

Reopening

Petition to Reopen (DIA WCAB 42)

Reports of Employee, Employer, and Physician

Medical Mileage Expense Forms

Medical Mileage Expense Form (for mileage or after 1/1/2010)
Medical Mileage Expense Form (Blank Form)
Medical Mileage Expense Form (for travel on or after 1/1/09)
Medical Mileage Expense Form (for travel on or after 7/1/08)
Medical Mileage Expense Form (for travel on or after 1/1/08)
Medical Mileage Expense Form (for travel on or after 1/1/07)
Medical Mileage Expense Form (for travel between 7/1/06 and 1/1/07)
Medical Mileage Expense Form (for travel before 7/1/06)
Primary Treating Physician’s Progress Report (DWC PR 2)
Primary Treating Physician’s Permanent and Stationary Report (DWC PR 3)
Primary Treating Physician’s Permanent and Stationary Report (DWC PR 4)
Application for Spinal Surgery 2nd Opinion Physician List (DWC 232)
Objection to Treating Physician’s Recommendations for Spinal Surgery (DWC 233)
Employer’s Report of Occupational Injury or Illness (Form 5020)
Doctor’s First Report of Occupational Injury or Illness (DSLR 5021)
Employer’s Notice of Employee Death (DIA 510)
Predesignation of Personal Physician (DWC 9783)
Predesignation of Personal Physician (DWC 9783) (Spanish)
Notice of Personal Chiropractor or Personal Acupuncturist (DWC 9783.1)
Notice of Personal Chiropractor or Personal Acupuncturist (DWC 9783.1) (Spanish)
Notice to Employees Poster
Objection to Treating Doctor’s Report (WCU 33) (Word)
Objection to Treating Doctor’s Report (WCU 33) (WordPerfect)
Petition for Change of Primary Treating Physician (DWC 280A)
Response to Petition for Change of Primary Treating Physician (DWC 280B)
Physicians Guide Order Form
Treating Physician’s Determination of Medical Issues (IMC 81556)

Settlement Documents

Information Guidelines for Submission of Settlement Documents
Stipulations with Request for Award (Disability Case) (DWC-CA Form 10214 (a))
Stipulations with Request for Award (Death Case) (DWC-CA Form 10214 (b))
Compromise and Release (DWC-CA Form 10214 (c))
Compromise and Release (Dependency Claim) (DWC-CA Form 10214 (d))
Third Party Compromise and Release (DWC-CA 10214 (e))
Social Security Addendum (WCU 37)
Social Security Addendum (WCU 37) (Instructions)
Order Approving Compromise and Release (DIA WCAB 65)
Order Approving Compromise and Release (Third Party Settlement) (DIA WCAB 67)

Stipulations with Request for Award

Stipulations with Request for Award (Disability Case) (DWC-CA Form 10214 (a))
Stipulations with Request for Award (Death Case) (DWC-CA Form 10214 (b))
Stipulation and Award and/or Order (DWC WCAB 5)

Subpoenas and Discovery

Motion to Quash Subpoena Duces Tecum (WCU 14) (Word)
Motion to Quash Subpoena Duces Tecum (WCU 14) (WordPerfect)
Order Limiting Motion to Quash Subpoena Duces Tecum (WCU 15) (Word)
Order Limiting Motion to Quash Subpoena Duces Tecum (WCU 15) (WordPerfect)
Letter to Physician Regarding Motion to Quash Subpoena Duces Tecum (WCU 16) (Word)
Letter to Physician Regarding Motion to Quash Subpoena Duces Tecum (WCU 16) (WordPerfect)
Letter to Copy Service Regarding Motion to Quash Subpoena Duces Tecum (WCU 17) (Word)
Letter to Copy Service Regarding Motion to Quash Subpoena Duces Tecum (WCU 17) (WordPerfect)
Application for Issuance of Discovery Order (WCU 27) (Word)
Application for Issuance of Discovery Order (WCU 27) (WordPerfect)
Notice of Taking Deposition by Oral Examination (WCU 30) (Word)
Notice of Taking Deposition by Oral Examination (WCU 30) (WordPerfect)
Notice to Appear at Hearing and Produce Documents (WCU 31) (Word)
Notice to Appear at Hearing and Produce Documents (WCU 31) (WordPerfect)
Petition for Pre-Application Discovery Order (WCAB 30)
Subpoena (DIA WCAB 30)
Subpoena Duces Tecum (DIA WCAB 32)

Supplemental Job Displacement

Mandatory Notices for Vocational Training and Return to Work (Instructions)
Notice of Potential Right to Supplemental Job Displacement Benefit Form
Notice of Offer of Regular Work (DWC-AD 100118) (SJDB)
Notice of Offer of Regular Work (DWC-AD 100118)(SJDB) (Spanish)
Request for Reimbursement of Accommodation Expenses (DWC-AD 10120)(SJDB)
Notice of Offer of Modified or Alternative Work (DWC-AD 10133.53)(SJDB)
Notice of Offer of Modified or Alternative Work (DWC-AD 10133.53)(SJDB) (Spanish)
Request for Dispute Resolution Before the Administrative Director (DWC-AD 10133.55)(SJDB)
Supplemental Job Displacement Nontransferable Training Voucher (DWC-AD 10133.57)(SJDB)

Termination of Liability

Petition to Terminate Liability for Temporary Disability Indemnity (DWC WCAB 46)

Third-Party Actions

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

Uninsured Employers Fund

Special Notice of Lawsuit (WCU 7)

Utilization Review

Utilization Review (UR) Complaint Form (DWC UR 1)

Vocational Rehabilitation

Model Benefit Notices Regarding Vocational Rehabilitation

Vocational Rehabilitation Notices–Title 8, CCR § 9813(a)-(d) (Word) (Claims Adjuster Instructions)
Vocational Rehabilitation Notices–Title 8, CCR § 9813(a)-(d) (WP) (Claims Adjuster Instructions)
VRM Allowance Start/Resume – VR Temporary Disability Start/Resume (WordPerfect)
Potential Eligibility and Delay (Word)
Potential Eligibility and Delay (WordPerfect)
Potential Eligibility and Subsequent Delay (Word)
Potential Eligibility and Subsequent Delay (WordPerfect)
Denial Vocational Rehabilitation (Word)
Denial Vocational Rehabilitation (WordPerfect)
Notice of Interruption or Deferral of Vacational Rehabilitation Services (Word)
Notice of Interruption or Deferral of Vacational Rehabilitation Services (WordPerfect)
Vocational Rehabilitation Reinstatement Request (Word)
Vocational Rehabilitation Reinstatement Request (WordPerfect)
90 Days of Total Disability (Word)
90 Days of Total Disability (WordPerfect)
Potential Eligibility (Word)
Potential Eligibility (WordPerfect)
Reminder of Potential Eligibility (Word)
Reminder of Potential Eligibility (WordPerfect)
Intention to Withhold Maintenance Allowance for Failure to Cooperate (Word)
Intention to Withhold Maintenance Allowance for Failure to Cooperate (WordPerfect)
Vocational Rehabilitation Reply Form (Word)
Vocational Rehabilitation Reply Form (WordPerfect)
VRM Allowance Start/Resume – VR Temporary Disability Start/Resume (Word)
Appeal from Determination and Order of the Rehabilitation Unit (WCU 35)
Appeal from the Determination (or Decision and Order) of the Rehab. Unit (WCU 35) (Word)
Appeal from the Determination (or Decision and Order) of the Rehab. Unit (WCU 35) (WordPerfect)
Treating Physician’s Report of Disability Status (DWC RU 90)
Description of Employee’s Job Duties (DWC RU 91)
Notice of Offer of Modified or Alternate Work (DWC RU 94)
Notice of Offer of Modified or Alternate Work (DWC RU 94) (Spanish)
Case Initiation Document (DWC RU 101)
Vocational Rehabilitation Plan (Voc. Rehab. §10133.13) (RU 102)
Request for Dispute Resolution (Voc. Rehab. §10133.14) (RU 103)
Notice of Termination of Rehabilitation Services (Voc. Rehab. §10133.16) (RU 105)
Request for Conclusion of Rehabilitation Benefits (DWC RB 105)
Employee Statement of Declination of Vocational Rehabilitation Services (DWC RU 107)
Employee Statement of Declination of Vocational Rehabilitation Services (DWC RU 107) (Spanish)
Employee Statement of Declination of Vocational Rehabilitation Services (DWC RU 107 A)
Employee Statement of Declination of Vocational Rehabilitation Services (DWC RU 107 A) (Spanish)
Initial Evaluation Summary (DWC RU 120)
Vocational Rehabilitation Progress Report (DWC RU 121)
Settlement of Prospective Vocational Rehabilitation Services [LC § 4646(b)] (RU 122)

Walk-Through

Request for Walk-Through Declarations of Readiness ONLY (CAWC0001)
Request for Walk-Through Settlements, Attorneys’ Fees, Petitions to Compel Attendance (CAWC0002)
Request for Walk-Through Declarations of Readiness ONLY - Notice Waived Basis ONLY (CAWC0003)

WCAB Case Information and Action

Request to View a WCAB Case File (DWC AD 1)
Request for WCAB Case # Search (DWC AD 2)
Request for DWC Authorization Number (DWC AD 3)
File Request for WCAB Action--Walk Through (WCU 8)
WCAB Data Entry Sheet (WCU 9)
Public Records Act Request Form (WCU 38)