LexisNexis® Automated California Workers' Compensation Forms

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Publisher: Matthew Bender
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ISBN: 9780820546650
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Product description

To purchase this product or to learn more please call 1-888-AT-LEXIS or click here to request a call back from a LexisNexis Sales Representative.

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

* Please refer to software and system requirements below.

Software Requirements

The Downloadable Content format is not compatible with Mac or tablet PCs. HotDocs®, the platform on which the Drafting System operates, does not support WordPerfect X8.

This publication is intended to provide authoritative information regarding the subjects covered. Efforts have been made to ensure that information is current and accurate, within the constraints of publication schedules. It is sold with the understanding that neither the publisher nor the authors and commentators are engaged in rendering legal services. If legal advice or other expert assistance is required, the services of a competent professional should be sought.

NOTE: THIS PROGRAM IS INTENDED FOR USE BY LICENSED ATTORNEYS. IT IS NOT A SUBSTITUTE FOR INDEPENDENT THINKING. YOU SHOULD FAMILIARIZE YOURSELF WITH RELEVANT STATUTES, CASE LAW, AND STANDARDS OF PRACTICE, AND THOROUGHLY REVIEW ALL GENERATED DOCUMENTS.

System Requirements

To ensure the best performance please note the following minimum requirements for hardware and software:

Hardware Requirements for Running HotDocs
•  1 GHz processor (2 GHz or faster recommended)
•  1 GB RAM (2 GB, recommended)
•  300 MB hard disk space for installation process, 85 MB thereafter
•  1024 x 768 screen resolution

Software Requirements for Running HotDocs
•  Microsoft Windows Vista (32-bit or 64-bit), Windows 7 (32-bit or 64-bit), Windows 8 (32-bit or 64-bit), or Windows 10 (32-bit or 64-bit)
•  Microsoft Internet Explorer 8.0 or later
•  Microsoft Word 2003, 2007, 2010, 2013, or 2016
•  Corel WordPerfect X4, X5, X6 or X7

Purchase price includes free training.

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Table of contents

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

    Audit Referral Form (DWC AU 906)
    How to file a complaint with the Audit & Enforcement Unit (DWC AU 905)

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-WCAB 10208.3)
    Minutes of Hearing (DWC-CA Form 10245)
    Minutes of Hearing (WCAB Form 20)
    Objection to Declaration of Readiness to Proceed (WCU 32) (Word)
    Objection to Declaration of Readiness to Proceed (WCU 32) (WordPerfect)
    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)
    Supplement to Minutes (WCAB Form 20.1)

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

    DWC Fact Sheet A, Answers to Your Questions About Utilization Review (Word)
    DWC Fact Sheet A, Answers to Your Questions About Utilization Review (WordPerfect)
    DWC Fact Sheet B, Glossary of Workers' Compensation Terms for Injured Workers
    Sample Initial Written Employee Notification Re: Medical Provider Network (Spanish)
    DWC Fact Sheet B, Glossary of Workers' Compensation Terms for Injured Workers (Word)
    DWC Fact Sheet B, Glossary of Workers' Compensation Terms for Injured Workers (WordPerfect)
    DWC Fact Sheet C, Answers to Your Questions About Temporary Disability Benefits (Word)
    DWC Fact Sheet C, Answers to Your Questions About Temporary Disability Benefits (WordPerfect)
    DWC Fact Sheet D, Answers to Your Questions About Permanent Disability Benefits (Word)
    DWC Fact Sheet D, Answers to Your Questions About Permanent Disability Benefits (WordPerfect)
    DWC Fact Sheet E, Answers to Your Questions About Qualified Medical Evaluators (Spanish)
    DWC Fact Sheet E, Answers to Your Questions About Qualified Medical Evaluators (Word)
    DWC Fact Sheet E, Answers to Your Questions About Qualified Medical Evaluators (WordPerfect)
    DWC Fact Sheet F, 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 (Word)
    DWC Fact Sheet F, Answers to Your Questions About the State's Uninsured Employers Fund (WordPerfect)

EAMS (Scanner OCR Forms)

    Court Administrator Forms
        Arbitration Submittal Form (DWC-CA Form 10297)
        Compromise and Release (Dependency Claim) (DWC-CA Form 10214 (d))
        Compromise and Release (DWC-CA Form 10214 (c))
        Cover Sheet (DWC-CA Form 10232.1)
        Cover Sheet (DWC-CA Form 10232.1) (Instruction Tables)
        Cover Sheet and Separator Sheet (combined)
        Declaration of Readiness to Proceed (DWC-CA Form 10250.1)
        Document Separator Sheet (DWC-CA Form 10232.2)
        Document Separator Sheet (DWC-CA Form 10232.2) (Document List)
        Declaration of Readiness to Proceed to Expedited Hearing (Trial) (LC §5502(b)) (DWC-WCAB 10208.3)
        Lien Conference Disposition (WCAB Form 27)
        Pre-Trial Conference Statement (DWC-CA Form 10253.1)
        Pre-Trial Conference Statement (Multiple Parties) (DWC-CA Form 10253.1)(Last Page)
        Stipulations with Request for Award (Death Case) (DWC-CA Form 10214 (b))
        Stipulations with Request for Award (Disability Case) (DWC-CA Form 10214 (a))
        Third Party Compromise and Release (DWC-CA 10214 (e))
    Disability Evaluation Unit (DEU) Forms
        Request for Consultative Rating (RCR) (DWC-AD Form 104 (DEU))
        Request for Reconsideration of Summary Rating by the Administrative Director (DWC-AD Form 103 (DEU))
        Request for Summary Rating Determination of Primary Treating Physician's RPT (DWC-AD Form 102 (DEU))
        Request for Summary Rating Determination of Qualified Medical Examiner's RPT (DWC-AD Form 101 (DEU))
    EAMS-OCR Handbook of Instructions
    Retraining and Return to Work Unit (RRTW) Forms
        Notice of Offer of Modified or Alternative Work (DWC-AD 10133.53)(SJDB)
        Notice of Offer of Regular Work (DWC-AD 100118) (SJDB)
        Request for Dispute Resolution Before the Administrative Director (DWC-AD 10133.55)(SJDB)
        Request for Reimbursement of Accommodation Expenses (DWC-AD 10120)(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 List
    EDEX Subscriber Agreement

Enforcement of Awards

    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)
    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)

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

    AME or QME Declaration of Service of Medical – Legal Report (QME Form 122)
    Application for Appointment as Qualified Medical Evaluator (QME Form 100)
    Course Evaluation for Administrative Director (QME Form 117)
    Declaration Regarding Protection of Mental Health Record (QME Form 121)
    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 (Injury After 2005)
    Provider’s Request for Second Bill Review (DWC Form SBR-1)
    QME Disclosure of Specified Financial Interests (QME Form 124)
    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/AME Time Frame Extension Report (QME Form 112)
    Qualified Medical Evaluator Complaint Form (AD Form 1)
    Qualified Medical Evaluator Fees (QME Form 103)
    Reappointment Application as Qualified Medical Evaluator (QME Form 104)
    Registration for QME Competency Examination (QME Form 102)
    Replacement Panel Request (QME 31.5)
    Request for Authorization for Medical Treatment (DWC Form RFA)
    Voluntary Directive for Alternate Service of Medical-Legal EVAL. Report on Disputed Injury to Psyche

Medical Provider Networks

    Cover Page for Medical Provider Network Application (DWC 9767.4)
    DWC Medical Provider Network Complaint Form (DWC 9767.16.5)
    DWC Petition for Suspension or Revocation of a Medical Provider Network Form (DWC 9767.17.5-Part A)
    Notice of Medical Provider Network Plan Modification (DWC 9767.8)
    Sample Initial Written Employee Notification Letter
    Sample Initial Written Employee Notification Lette (WordPerfect)
    Sample Initial Written Employee Notification Letter (Spanish)
    Sample Initial Written Employee Notification Letter (Spanish) (WordPerfect)
    Sample Initial Written Employee Notification Re: Medical Provider Network

Model Benefit Notices - Notice to Provide Panel QME Request Form

    Notice Regarding QME Panel Request Form (Word)
    Notice Regarding QME Panel Request Form (WordPerfect)
    Notice to Provide Panel QME Request Form for Workers' Compensation Benefits 8 CCR §9812(i) (Word)
    Notice to Provide Panel QME Request Form for Workers' Compensation Benefits 8 CCR §9812(i) (WP)

Model Benefit Notices Regarding Denial of Benefit and Delay of Benefit

    Notice of Delay in Determining Liability for Workers' Compensation Benefits 8 CCR §9812(g) (Word)
    Notice of Delay in Determining Liability for Workers' Compensation Benefits 8 CCR §9812(g) (WP)
    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 Delay of Workers' Compensation Benefit (Word)
    Notice Regarding Delay of Workers' Compensation Benefit (WordPerfect)
    Notice Regarding Denial of Workers' Compensation Benefit (Word)
    Notice Regarding Denial of Workers' Compensation Benefit (WordPerfect)

Model Benefit Notices Regarding Dependency

    Notice Regarding Dependency Benefits – Delay (Word)
    Notice Regarding Dependency Benefits – Delay (WordPerfect)
    Notice Regarding Dependency Benefits – Denial (Word)
    Notice Regarding Dependency Benefits – Denial (WordPerfect)
    Notice Regarding Dependency Benefits – First Payment (Word)
    Notice Regarding Dependency Benefits – First Payment (WordPerfect)
    Notice Regarding Dependency Benefits Change in Payment or Benefit Ending (Word)
    Notice Regarding Dependency Benefits Change in Payment or Benefit Ending (WP)
    Notices Regarding Workers' Compensation Dependency Benefits (Word) (Claims Adjuster Instructions)
    Notices Regarding Workers' Compensation Dependency Benefits (WP) (Claims Adjuster Instructions)

Model Benefit Notices Regarding Permanent Disability

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

Model Benefit Notices Regarding Temporary Disability and Salary Continuation

    Delay Temporary Disability (Word)
    Delay Temporary Disability (WordPerfect)
    Denial Temporary Disability (Word)
    Denial Temporary Disability (WordPerfect)
    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)

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
    Apportionment Referral (DEU Form 105)
    Notice of Options Following Permanent Disability Rating (DEU Form 110)
    Request for Consultative Rating (RCR) (DWC-AD form 104 (DEU))
    Request for Reconsideration of Summary Rating by the Administrative Director (DWC-AD Form 103 (DEU))
    Request for Summary Rating Determination of Primary Treating Physician's RPT (DWC-AD Form 102 (DEU))
    Request for Summary Rating Determination of Qualified Medical Examiner's RPT (DWC-AD Form 101 (DEU))

Pleadings

    Addendum to Application for Adjudication of Claim to Identify Legal Entity Employing Injure (WCAB 2)
    Addendum to the Application and/or Answer (WCU 4)
    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)
    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)
    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)
    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

    Finding Order (Additional Panel QME-Unrepresented)
    Order Additional Panel QME-Represented
    Proof of Service by Mail (WCU 10) (Word)
    Proof of Service by Mail (WCU 10) (WordPerfect)
    Replacement Panel Represented
    Unrepresented Replacement Panel
    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 (Blank Form)
        Medical Mileage Expense Form (for travel on or after Jan 1, 2020 and before Dec 31, 2020)
        Medical Mileage Expense Form (for travel on or after Jan 1, 2019 and before Dec 31, 2019)
        Medical Mileage Expense Form (for travel on or after Jan 1, 2018 and before Dec 31, 2018)
        Medical Mileage Expense Form (for travel on or after Jan 1, 2017 and before Dec 31, 2017)
    Doctor's First Report of Occupational Injury or Illness (DSLR 5021)
    Employer's Notice of Employee Death (DIA 510)
    Employer's Report of Occupational Injury or Illness (Form 5020)
    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)
    Predesignation of Personal Physician (DWC 9783)
    Predesignation of Personal Physician (DWC 9783) (Spanish)
    Primary Treating Physician's Permanent and Stationary Report (DWC PR 3)
    Primary Treating Physician's Permanent and Stationary Report (DWC PR 4)
    Primary Treating Physician's Progress Report (DWC PR 2)
    Response to Petition for Change of Primary Treating Physician (DWC 280B)
    Treating Physician's Determination of Medical Issues (IMC 81556)

Settlement Documents

    Compromise and Release (Dependency Claim) (DWC-CA Form 10214 (d))
    Compromise and Release (DWC-CA Form 10214 (c))
    Information Guidelines for Submission of Settlement Documents
    Order Approving Compromise and Release (DIA WCAB 65)
    Order Approving Compromise and Release (Third Party Settlement) (DIA WCAB 67)
    Social Security Addendum (WCU 37)
    Social Security Addendum (WCU 37) (Instructions)
    Stipulations with Request for Award (Death Case) (DWC-CA Form 10214 (b))
    Stipulations with Request for Award (Disability Case) (DWC-CA Form 10214 (a))
    Stipulations with Request for Award (Disability Case) (DWC-WCAB Form 10214 (a)-1)
    Third Party Compromise and Release (DWC-CA 10214 (e))

Stipulations with Request for Award

    Stipulation and Award and/or Order (DWC WCAB 5)
    Stipulations with Request for Award (Death Case) (DWC-CA Form 10214 (b))
    Stipulations with Request for Award (Disability Case) (DWC-CA Form 10214 (a))
    Stipulations with Request for Award (Disability Case) (DWC-WCAB Form 10214 (a)-1)

Subpoenas and Discovery

    Application for Issuance of Discovery Order (WCU 27) (WordPerfect)
    Letter to Copy Service Regarding Motion to Quash Subpoena Duces Tecum (WCU 17) (WordPerfect)
    Motion to Quash Subpoena Duces Tecum (WCU 14) (Word)
    Motion to Quash Subpoena Duces Tecum (WCU 14) (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)
    Order Limiting Motion to Quash Subpoena Duces Tecum (WCU 15) (Word)
    Order Limiting Motion to Quash Subpoena Duces Tecum (WCU 15) (WordPerfect)
    Petition for Pre-Application Discovery Order (WCAB 30)
    Subpoena (DIA WCAB 30)
    Subpoena Duces Tecum (DWC WCAB 32)

Supplemental Job Displacement

    Description of Employee's Job Duties (DWC-AD 10133.33) (SJDB)
    Mandatory Notices for Vocational Training and Return to Work (Instructions)
    Notice of Offer of Modified or Alternative Work (DWC-AD 10133.35)(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)
    Notice of Offer of Regular Work (DWC-AD 10118)(SJDB)
    Notice of Offer of Regular Work (DWC-AD 10118)(SJDB) (Spanish)
    Physician's Report of Permanent and Stationary Status and Work Capacity (DWC-AD 10133.36)(SJDB)
    Request for Dispute Resolution Before the Administrative Director (DWC-AD 10133.55)(SJDB)
    Request for Reimbursement of Accommodation Expenses (DWC-AD 10120)(SJDB)
    Supplemental Job Displacement Nontransferable Training Voucher (DWC-AD 10133.57)(SJDB)
    Supplemental Job Displacement Non-Transferable Voucher (DWC-AD 10133.32)

Termination of Liability

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

Third-Party Actions

    Complaint for Compensatory and Punitive Damages by Injured Employee... (577-525) (Word)
    Complaint for Compensatory and Punitive Damages by Injured Employee... (577-525) (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 Damages by Injured Employee Against Negligent... (577-522) (Word)
    Complaint for Compensatory Damages by Injured Employee Against Negligent... (577-522) (WordPerfect)
    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)
    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)
    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)
    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)
    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)

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
        90 Days of Total Disability (Word)
        90 Days of Total Disability (WordPerfect)
        Denial Vocational Rehabilitation (Word)
        Denial Vocational Rehabilitation (WordPerfect)
        Potential Eligibility (Word)
        Potential Eligibility (WordPerfect)
        Potential Eligibility and Delay (Word)
        Potential Eligibility and Delay (WordPerfect)
        Potential Eligibility and Subsequent Delay (Word)
        Potential Eligibility and Subsequent Delay (WordPerfect)
        Reminder of Potential Eligibility (Word)
        Reminder of Potential Eligibility (WordPerfect)
        VRM Allowance Start/Resume – VR Temporary Disability Start/Resume (Word)
        VRM Allowance Start/Resume – VR Temporary Disability Start/Resume (WordPerfect)
    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)
    Case Initiation Document (DWC RU 101)
    Description of Employee's Job Duties (DWC RU 91)

Walk-Through

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

WCAB Case Information and Action

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