LexisNexis® Automated California Workers' Compensation Forms

Access the most comprehensive source for electronically automated Workers' Compensation Forms.
Publisher: Matthew Bender
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ISBN: 9780820546650
Publisher: Matthew Bender
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Book Edition: 20

Product details

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

View System Requirements

Purchase price includes free training.

Table of Contents





LexisNexis Automated California Workers' Compensation Forms



Interview Forms

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

Audit Referral Form (DWC AU 906)

How to File a Complaint with the Audio 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

DWC Fact Sheet (Spanish)

DWC Fact Sheet (Word)

DWC Fact Sheet (WordPerfect)

DWC Fact Sheet A, Answers to Your Questions About Utilization Review

DWC Fact Sheet A, Answers to Your Questions About Utilization Review (Spanish)

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

DWC Fact Sheet B, Glossary of Workers' Compensation Terms for Injured Workers (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

DWC Fact Sheet C, Answers to Your Questions About Temporary Disability Benefits (Spanish)

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

DWC Fact Sheet D, Answers to Your Questions About Permanent Disability Benefits (Spanish)

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

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 (Spanish)

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)

EAMS-OCR Handbook of Instructions

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

Employee's Permanent Disability Questionnaire (DWC-AD Form 100 (DEU))

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))

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 Acknowledgment of Legal Constraints on Access to Information and Use of Information

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

Additional Panel Request (QME 31.7)

AME or QME Declaration of Service of Medical - Legal Report (QME Form 122)

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)

Application for Appointment as Qualified Medical Evaluator (QME Form 100)

Application for Independent Medical Review (DWC form IMR)

Course Evaluation for Administrative Director (QME Form 117)

Declaration Regarding Protection of Mental Health Record (QME Form 121)

Faculty Disclosure of Commercial Interest (QME Form 119)

Independent Medical Review Application (DWC 9768.10)

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)

Notice of Qualified Medical Evaluator Unavailability (QME Form 109)

Official Medical Fee Schedule Order Form (GS 2055)

Physician Contract Application (Independent Medical Reviewer) (DWC 9768.5)

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 Appointment Notification Form (QME Form 110)

Qualified Medical Evaluator Complaint Form (AD Form 1)

Qualified Medical Evaluator Exam Packet (QME 100)

Qualified Medical Evaluator Fees (QME Form 103)

Qualified Medical Evaluator Letter (QME Form 108)

Qualified or Agreed Medical Evaluator's Findings Summary (QME Form 111)

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)

Request for Factual Correction of an Unrepresented Panel QME Report (QME Form 37)

Request for Independent Bill Review (DWC Form IBR-1)

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 Letter (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

Sample Initial Written Employee Notification Re: Medical Provider Network (Spanish)

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)

Employee's Permanent Disability Questionnaire (DWC-AD Form 100 (DEU))

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)

Notice of Options Following Permanent Disability Rating (DEU Form 110)

Request for Consultative Rating (RCR) (DWC-AD form 104 (DEU))

Request for Informal Rating (DEU 201)

Request for Informal Rating (DIA 201)

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 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)

For Changes Needed on Official Address Record (Form WCAB-001)

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

Application for Spinal Surgery 2nd Opinion Physician List (DWC 232

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)

Objection to Treating Physician's Recommendations for Spinal Surgery (DWC 233)

Petition for Change of Primary Treating Physician (DWC 280A)

Physicians Guide Order Form

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

Medical Mileage Expense Forms

Medical Mileage Expense Form (Blank Form)

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)

Medical Mileage Expense Form (for travel on or after Jan 1, 2016 and before Dec 31, 2016)

Medical Mileage Expense Form (for travel on or after Jan 1, 2015 and before Dec 31, 2015)

Medical Mileage Expense Form (for travel on or after Jan 1, 2014 and before Dec 31, 2014)

Medical Mileage Expense Form (for travel on or after Jan 1, 2013 and before Dec 31, 2013)

Medical Mileage Expense Form (for travel on or after Jul 1, 2011 and before Dec 31, 2012)

Medical Mileage Expense Form (for travel on or after Jan 1, 2011 and before Jun 30, 2011)

Medical Mileage Expense Form (for travel on or after Jan 1, 2010 and before Dec 31, 2010)

Medical Mileage Expense Form (for travel on or after Jan 1, 2009 and before Dec 31, 2009)

Medical Mileage Expense Form (for travel on or after Jul 1, 2008 and before Dec 31, 2008)

Medical Mileage Expense Form (for travel on or after Jan 1, 2008 and before Jun 30, 2008)

Medical Mileage Expense Form (for travel on or after Jan 1, 2007 and before Dec 31, 2007)

Medical Mileage Expense Form (for travel on or after Jul 1, 2006 and before Dec 31, 2006)

Medical Mileage Expense Form (for travel on or after Jul 1, 2005 and before Jun 30, 2006)

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) (Word)

Application for Issuance of Discovery Order (WCU 27) (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)

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)

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 (DIA 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)

Notice of Potential Right to Supplemental Job Displacement Benefit Form

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

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)

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)

Employee Statement of Declination of Vocational Rehabilitation Services (DWC RU 107)

Employee Statement of Declination of Vocational Rehabilitation Services (DWC RU 107) (Spanish)

Initial Evaluation Summary (DWC RU 120)

Notice of Offer of Modified or Alternate Work (DWC RU 94)

Notice of Offer of Modified or Alternate Work (DWC RU 94) (Spanish)

Request for Conclusion of Rehabilitation Benefits (DWC RB 105)

Treating Physician's Report of Disability Status (DWC RU 90)

Vocational Rehabilitation Progress Report (DWC RU 121)

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)

Intention to Withhold Maintenance Allowance for Failure to Cooperate (Word)

Intention to Withhold Maintenance Allowance for Failure to Cooperate (WordPerfect)

Notice of Interruption or Deferral of Vacational Rehabilitation Services (Word)

Notice of Interruption or Deferral of Vacational Rehabilitation Services (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)

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)

Vocational Rehabilitation Reinstatement Request (Word)

Vocational Rehabilitation Reinstatement Request (WordPerfect)

Vocational Rehabilitation Reply Form (Word)

Vocational Rehabilitation Reply Form (WordPerfect)

VRM Allowance Start/Resume - VR Temporary Disability Start/Resume (Word)

VRM Allowance Start/Resume - VR Temporary Disability Start/Resume (WordPerfect)

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)