CaliforniaDWC forms
California DWC forms.
Official catalogue, by number. Download the state’s PDF. Where a form is what a panel actually ruled on, the nested page quotes that ruling.
- Forms
- 118
- Pages with a stated purpose
- 29
- Languages
- 7
How to fill a DWC form, from the state.
Frequently used forms11
- DWC - AD 10133.32Supplemental job displacement non-transferable voucherEnglish · Spanish · Chinese · Korean · Tagalog · VietnameseOfficial PDF →
- DWC - AD 10133.36Physician's return-to-work & voucher reportOfficial PDF →
- DWC 1Workers' compensation claim formEnglish / Spanish · Chinese · Korean · Tagalog · VietnameseOfficial PDF →
- DWC 7Official PDF →
- Mileage formOfficial PDF →
- QME 105Request For QME panel under Labor Code Section 4062.1English · SpanishOfficial PDF →
- QME 106Official PDF →
- QME 31.5Replacement panel requestOfficial PDF →
- QME 31.7Additional QME panel requestOfficial PDF →
- WCAB 20Minutes of hearingOfficial PDF →
- WCAB 24Pre-trial conference statementOfficial PDF →
QME/AME forms17
- QME 100Application for appointment as qualified medical evaluatorOfficial PDF →
- QME 102Registration for QME competency examinationOfficial PDF →
- QME 104Reappointment application as qualified medical evaluatorOfficial PDF →
- QME 108Notice to Injured Worker regarding QME ExamOfficial PDF →
- QME 109QME notice of unavailabilityOfficial PDF →
- QME 110QME appointment notification formOfficial PDF →
- QME 111Qualified medical evaluator's findings summary form - unrepresented cases onlyOfficial PDF →
- QME 112QME/AME report time frame extension requestOfficial PDF →
- QME 117Course Evaluation for Administrative Director (QME)Official PDF →
- QME 118Official PDF →
- QME 119Faculty disclosure of commercial interestOfficial PDF →
- QME 120Voluntary directive for alternate service of medical-legal evaluation report on disputed injury to psycheOfficial PDF →
- QME 121Declaration regarding protection of mental health recordOfficial PDF →
- QME 122AME or QME declaration of service of medical - legal reportOfficial PDF →
- QME 123Official PDF →
- QME 124QME disclosure of specified financial interestsOfficial PDF →
- QME 37Request for Factual Correction of a Unrepresented Panel QME ReportOfficial PDF →
Court forms41
- —Application for benefits for serious and willful misconduct of employerOfficial PDF →
- —Application for discrimination benefits pursuant to Labor Code section 132 - AOfficial PDF →
- —Arbitrator ApplicationOfficial PDF →
- —Declaration pursuant to Labor Code section 4906(h)Official PDF →
- DIA 2Application for adjudication of claim - Death caseOfficial PDF →
- DIA 510Notice of employee deathOfficial PDF →
- DWC 280Petition for change of primary treating physicianOfficial PDF →
- DWC 3Attorney Fee Disclosure StatementEnglish · SpanishOfficial PDF →
- DWC 5Request for accommodations by persons with disabilityOfficial PDF →
- DWC WCAB 30SubpoenaOfficial PDF →
- DWC WCAB 32Subpoena Duces TecumOfficial PDF →
- DWC WCAB 36Substitution of attorneysOfficial PDF →
- DWC WCAB 37Notice of dismissal of attorneyOfficial PDF →
- DWC WCAB 42Official PDF →
- DWC WCAB 45Petition for reconsiderationOfficial PDF →
- DWC WCAB 49Official PDF →
- DWC WCAB 8Petition for appointment of guardian ad litem and trusteeOfficial PDF →
- DWC-CA 10208.3Declaration of readiness to proceed - expedited trialOfficial PDF →
- DWC-CA 10214-aOfficial PDF →
- DWC-CA 10214-bStipulations with request for award - death caseOfficial PDF →
- DWC-CA 10214-cCompromise and releaseOfficial PDF →
- DWC-CA 10214-dCompromise and release - dependency claimOfficial PDF →
- DWC-CA 10214-eCompromise and release - third partyOfficial PDF →
- DWC-CA 10232.1Document cover sheetEnglish · SpanishOfficial PDF →
- DWC-CA 10232.2Official PDF →
- DWC-CA 10250.1Declaration of readiness to proceedOfficial PDF →
- DWC-CA form 10297Arbitrator submittalOfficial PDF →
- —Information guidelines for submission of settlement documentsOfficial PDF →
- —Proof of serviceOfficial PDF →
- —Special notice of lawsuitOfficial PDF →
- —VerificationOfficial PDF →
- —Verification formOfficial PDF →
- —Verification formOfficial PDF →
- WCAB 1Official PDF →
- WCAB 10Answer to application for adjudication of claimOfficial PDF →
- WCAB 2Addendum to application for adjudication of claim to identify legal entity employing injured workerOfficial PDF →
- WCAB 20.1Supplement to minutes of hearingOfficial PDF →
- WCAB 20.2Minutes of hearing - addendumOfficial PDF →
- WCAB 24.1Pre-trial conference statement lien issues addendumOfficial PDF →
- WCAB 46Petition to terminate liability for temporary disability indemnityOfficial PDF →
- WCAB 6Notice and request for allowance of lienOfficial PDF →
Medical forms5
- 5021Official PDF →
- 9785.5Request for authorization for medical treatmentOfficial PDF →
- DWC PR-2Official PDF →
- DWC PR-3Official PDF →
- DWC PR-4Official PDF →
Disability Evaluation forms8
- —Commutation requestOfficial PDF →
- DEU 105Apportionment requestOfficial PDF →
- DEU 110Notice of options following disability ratingEnglish · SpanishOfficial PDF →
- DWC-AD 100Employee's permanent disability questionnaireEnglish · SpanishOfficial PDF →
- DWC-AD 101Request for summary rating determination of Qualified Medical Evaluator's (QME) ReportOfficial PDF →
- DWC-AD 102Request for summary rating determination - primary treating physician reportOfficial PDF →
- DWC-AD 103Request for reconsideration of summary rating by the administrative directorOfficial PDF →
- DWC-AD 104Request for consultative ratingOfficial PDF →
Supplemental Job Displacement Benefits forms5
- DWC-AD 10118Official PDF →
- DWC-AD 10133.33Description Of Employee's Job DutiesOfficial PDF →
- DWC-AD 10133.35Official PDF →
- DWC-AD 10133.53Official PDF →
- DWC-AD 10133.57Supplemental Job Displacement Nontransferable Training VoucherEnglish · SpanishOfficial PDF →
Independent Medical Review forms6
- —Authorized Representative Designation for Independent Medical ReviewOfficial PDF →
- DWC 9768.10Independent medical review applicationEnglish · SpanishOfficial PDF →
- DWC 9768.5Official PDF →
- DWC IMRApplication for Independent Medical ReviewOfficial PDF →
- —Petition appealing administrative director’s independent medical review determinationOfficial PDF →
- —Verification formOfficial PDF →
Medical Provider Network forms4
- DWC 5307.12Disclosure of contract reimbursement rateOfficial PDF →
- DWC 9767.17.5MPN response to petition for suspension or revocation of a medical provider network - Part BOfficial PDF →
- DWC 9767.4Cover page for medical provider network application or plan for reapprovalOfficial PDF →
- DWC 9767.8Notice of medical provider network plan modificationOfficial PDF →
Employer forms2
- DLSR 5020Employer's report of occupational injury or illnessOfficial PDF →
- DWC RGS-1Petition for permission to negotiate a section 3201.7 labor-management agreementOfficial PDF →
Pre-designation forms2
- DWC 9783Notice of pre-designation of personal physicianEnglish · SpanishOfficial PDF →
- DWC 9783.1Notice of personal chiropractor or personal acupuncturistEnglish · SpanishOfficial PDF →
Lien forms2
- Form ALien filing fees refund requestOfficial PDF →
- WCAB 27Lien conference dispositionOfficial PDF →
Audit forms3
- DWC-851Annual report of adjusting locations for claims administratorsOfficial PDF →
- DWC-AU-905Complaint form: Audit UnitEnglish · SpanishOfficial PDF →
- DWC-AU-906Audit referral formEnglish · SpanishOfficial PDF →
Complaint forms5
- —Complaint form: Qualified medical evaluator (QME)Official PDF →
- —Complaint form: Workers' Compensation JudgeOfficial PDF →
- DWC 9767.16.5Complaint form: Medical Provider NetworkOfficial PDF →
- DWC SMBFR 1115Report of suspected medical care provider fraudOfficial PDF →
- DWC UR 1Complaint form: Utilization reviewOfficial PDF →
Independent Bill Review forms2
- DWC Form IBR-1Request for independent bill reviewOfficial PDF →
- DWC Form SBR-1Provider's request for second bill reviewOfficial PDF →
Utilization Review forms1
- Form UR-01Utilization Review - UR-01Official PDF →
SIBTF/UEBTF forms3
- —Application for subsequent injuries fund benefitsOfficial PDF →
- DWC-UEF 50Application for discretionary payments from the uninsured employers' fundOfficial PDF →
- STD 204Payee Data RecordOfficial PDF →
Public records forms1
- —Request for public recordsOfficial PDF →
About these forms
Where can I download California DWC forms?
This hub lists the official catalogue by number — DWC-1, QME 105/106, mileage, and the rest — with the state’s PDF. A form gets its own URL only when DWC stated a purpose. How-to-fill instructions stay on DWC’s page, linked here.
Are these the current official forms?
They are the files DWC publishes. If the state replaces a PDF, we follow that file. This is not a filing portal and not legal advice on which form to use.
Private workspace
Your case already resembles someone else’s. Find whose.
Paste the dispute. The extractor builds the factors, the search finds the decisions the same facts won, and the matter stays saved. Free account.