California Workers' Compensation Forms Workers' Compensation Appeals Board Vocational Rehabilitation Disability Evaluation Audit Primary Treating Physician Reports Independent Medical Review Judicial Ethics Managed Care Employee and Employer Forms Qualified Medical Examiner Self Insurance Medical Provider Network U.S Department of Labor Forms Division of Federal Employees' Compensation Division of Longshore and Harbor Workers' Compensation Work Capacity Evaluation Occupational Safety and Health Administration (OSHA) [BScottHolmes RSS Feed]

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California Workers' Compensation Forms
Workers' Compensation Appeals Board
BulletAnswer
WCAB Form 2 (REV 4/1/90)

BulletAnswer Of ___
DIA WCAB 10 (Rev 7/81)

BulletAppeal From Determination and Order of the Rehabilitation Unit

BulletApplication for Adjudication of Claim
DIA WCAB Form 1 REV 7/81

BulletApplication for Adjudication of Claim
WCAB Form 1 (REV 2/91)

BulletApplication for Adjudication of Claim (Death Case)
WCAB Form 1A (REV 2/91)

BulletApplication for Benefits for Serious and Willful Misconduct of Employer

BulletApplication for Discrimination Benefits Pursuant to labor Code Section 132(A)

BulletApplication for Spinal Surgery 2nd Opinion Physician List
DWC Form 232 (12/2004)

BulletCompromise and Release
DIA WCAB FORM 15 (Rev 10/2005)

BulletCompromise and Release (Dependency Claim)
DWC WCAB 16 (Rev 10-92)

BulletConsultative Rating Request
DIA 11

BulletDeclaration of Readiness to Proceed
DWC WCAB 9 (Rev 1/1/03)

BulletDeclaration of Readiness To Proceed To Expedited Hearing (Trial)
DWC Form 4 (Rev.1/1/03)

BulletFee Disclosure Statement
DWC Form 3 (Rev. 3/93)

BulletFee Disclosure Statement (Spanish)
DWC Form 3-S

BulletInformation Request Form
WCAB 7A (Rev 5/92)

BulletInformation Response Form
WCAB 7B (Rev 5/92)

BulletMinutes of Hearing/Order/Order and Decision on Request for Continuance/Order Taking Off Calendar/Not

BulletNotice of Dismissal of Attorney
DWC WCAB FORM 37 (Rev 8-75)

BulletNotice of Offer of Modified or Alternative Work
DWC-AD-10133.53 (08/05)

BulletNotice Regarding Workers' Compensation Claim
WC-002

BulletObjection to Treating Physicians Recommendation for Spinal Surgery
DWC Form 233 (10/2004)

BulletOrder for Submittal to Arbitrator Panel/Agreed Arbitrator
WCAB 33 (New 2/91)

BulletOrder Joining Party Defendent
DIA WCAB FORM 53 (Rev 2/75)

BulletOrder of Dismissal
DIA WCAB FORM 51 (Rev 12/75)

BulletPetition for Benefits/Penalty
WC 100

BulletPetition for Order Allowing Attorney's Fees
WC 900

BulletPetition for Permanent Disability Rating
DIA WCAB FORM 41 (Rev 11/76)

BulletPetition for Permission to Negotiate a Section 3201.7 Labor-Management Agreement
DWC Form RGS-1 (012004)

BulletPetition for Reconsideration
DWC WCAB FORM 45 (Rev 3-76)

BulletPre-Trial Conference Statement Section 5502 (d)(3)

BulletRequest for Dismissal
DWC WCAB FORM 43 (Rev 3-90)

BulletRequest for Dispute Resolution Before the Administrative Director
DWC-AD-10133.55 (08/05)

BulletStipulation and Award and/or Order
DWC WCAB 5 (Rev 10/2005)

BulletStipulation and Order Granting Payment of Lien Claim
WC 903

BulletStipulations with Request for Award
DWC WCAB Form 3 (Rev 10/2005)

BulletStipulations with Request for Award (Death Case)
DIA WCAB 4 (Rev 2-75)

BulletSubstitution of Attorney
DIA WCAB FORM 36 (REV. 10-74)

BulletSupplemental Job Displacement Nontransferable Training Voucher Form
DWC-AD-10133.57 (06/05)

BulletThird-Party Compromise and Release
DIA WCAB FORM 17 (Rev 11/74)

Vocational Rehabilitation
BulletCase Initiation Document
DWC Form RU-101 (12/90)

BulletDescription of Employee's Job Duties
DWC Form RU-91 (1/95)

BulletEmployee Statement of Declination of Vocational Rehabilitation Services
DWC Form RU-107 (12/90)

BulletInitial Evaluation Summary
DWC Form RU-120 (Rev 1/03)

BulletNotice of Offer of Modified or Alternate Work
DWC-RU-94 (01/03) Section 10133.12

BulletNotice of Termination of Vocational Rehabilitation Services
DWC Form RU-105 (01/03)

BulletRequest for Conclusion Of Rehabilitation Benefits
DWC Form RB-105 (01/03)

BulletRequest for Dispute Resolution
DWC Form RU-103 (01/03)

BulletSettlement of Prospective Vocational Rehabilitiation Service
DWC Form RU-122 01/03

BulletStatement of Decline of Vocational Rehabilitation Benefits State of California
DWC Form RB-107 (pre 1/1/90)

BulletStatement of Decline of Vocational Rehabilitation Services
DWC Form RU-107A (1/94)

BulletTreating Physician's Report of Disability Status State of California
DWC Form RU-90 (12/90)

BulletVocational Rehabilitation Plan
DWC Form RU-102 (1/03)

BulletVocational Rehabilitation Progress Report
DWC Form RU-121 (Rev 9/98)

Disability Evaluation
BulletApportionment
DEU Form 105 (Rev 01/01/05)

BulletEmployee's Disability Questionnaire
DEU Form 100 (Rev 06-05)

BulletEmployee's Request for Informal Permanent Disability Rating
DIA Form 200 (Rev 2-86)

BulletNotice of Options Following Disability Rating
DEU Form 110 (Rev 06-05)

BulletRequest for Consultative Rating Consult Request Form
Rev Feb 2002

BulletRequest for Informal Rating By Insurance Carrier or Self-Insurer
Form DWC 201 (Rev 8/90)

BulletRequest for Reconsideration of Summary Rating By the Adminstrative Director
DEU Form 103 (Rev 06/02)

BulletRequest For Summary Rating Determination of Primary Treating Physician's Report
DEU Form 102 (2/95)

BulletRequest For Summary Rating Determination of Qualified Medical Evaluator's Report
DEU Form 101 (Rev 06-05)

Audit
BulletAudit Referal Form
DWC-AU-906 (Rev 08/04)

Primary Treating Physician Reports
BulletDoctor's First Report of Occupational Injury or Illness
Form 5021 (Rev 4) 1992

BulletPrimary Treating Physician's Permanent and Stationary Report
DWC Form PR-4 (Rev 06-05)

BulletPrimary Treating Physician's Permanent and Stationary Report
DWC Form PR-3 (Rev 06-05)

BulletPrimary Treating Physician's Progress Report
DWC Form PR-2 (Rev 06-05)

Independent Medical Review
BulletIndependent Medical Review Application
Mandatory Form 4/30/05

BulletPhysician Contract Application
DWC Form 9768.5 (Final Regulation April 19, 2005)

Judicial Ethics
BulletComplaint About a Workers' Compensation Administrative Judge
Labor Code Section 123.6 and Title 8, Cal Code Regs Section 9722.1

Employee and Employer Forms
BulletEmployer's Report of Occupational Injury or Illness
Form 5020 (Rev7) June 2002

BulletPetition for Change of Primary Treating Physician
DWC Form 280 (Part A)(1/01)

BulletWorkers' Compensation Claim Form
DWC-1 Rev. 7/1/04

Qualified Medical Examiner
BulletRequest for Qualified Medical Evaluator
IMC Form 106 Rev 4/14/00

Medical Provider Network
BulletCover Page for Medical Provider Network Application
DWC Mandatory Form Section 9767.4 - 09/15/05

BulletNotice of Medical Provider Network Plan Modification
DWC Mandatory Form - Section 9767.8 - 09/15/05

U.S Department of Labor Forms
Division of Federal Employees' Compensation
BulletAgreement and Undertaking
OWCP-1

BulletAttending Physician's Report
CA-20 Rev. Nov 1999

BulletClaimant Medical Reimbursement Form
CA-915 Feb 1999

BulletClaim for Compensation
CA-7 Rev Nov 1999

BulletClaim for Compensation By Parents, Brothers, Sisters, Grandparents, or Grandchildren
CA-5b Rev Jan 1997

BulletClaim for Compensation by Widow, Widower, and/or Children
CA-5 Rev Jan 1997

BulletClaim for Continuance of Compensation Under the Federal Employees Compensation Act
CA-12

BulletClaim for Reimbursement Assisted Reemployment
CA-2231

BulletDuty Status Report
CA-17 Rev Jan 1997

BulletEvidence Required in Support of a Claim
CA-35

BulletFederal Employee's Notice of Traumatic Injury and Claim for Continuation of Pay/Compensation
CA-1 Rev Apr 1999

BulletHealth Insurance Claim Form
Form CMS-1500 (08/05)

BulletHealth Insurance Claim Form
HCFA-1500 (12-90), RRB-1500, OWCP-1500

BulletLeave Buy Back Worksheet/Certification and Election
CA-7b June 1996

BulletMedical Travel Refund Request
OWCP-957 Rev Aug 2001

BulletNotice of Law Enforcement Officer's Death
CA-722

BulletNotice of Law Enforcement Officer's Injury or Occupational Disease
CA-721

BulletNotice of Occupational Disease and Claim for Compensation
CA-2 Rev Jan 1997

BulletNotice of Recurrence
CA-2a Rev Sept 1996

BulletOfficial Superior's Report of Employee's Death
CA-6 Rev Jan 1997

BulletOutline for Otologic Evaluation
CA-1332 Rev Jan 1997

BulletOverpayment Recovery Questionnaire
OWCP-20

BulletRehabilitation Action Report
OWCP-44

BulletRehabilitation Maintenance Certificate
OWCP-17

BulletReport of Termination of Disability and/or Payment
CA-3 Rev June 1988

BulletTime Analysis Form
CA-7a June 1996

BulletUniform Health Insurance Claim Form
UB-92 HCFA-1450

Division of Longshore and Harbor Workers' Compensation
BulletApplication for Continuation of Death Benefit for Student
LS-266 Rev. Jan. 2002

BulletApplication for Self-Insurance
LS-271 Rev. May 2003

BulletApproval of Compromise of Third Person Cause of Action
LS-33 Rev. Sept 1974

BulletAttending Physician's Supplementary Report
LS-204 Rev May 1998

BulletCertification of Funeral Expenses
LS-265 Rev. May 2002

BulletClaimant's Statement
LS-267 Rev. May 1998

BulletClaim for Death Benefits
LS-262 Rev. Sept. 1998

BulletEmployee's Claim for Compensation
LS-203 Rev Sept 1998

BulletEmployer's First Report of Injury or Occupational Illness
LS-202 Rev Oct 1998

BulletEmployer's Supplementary Report of Accident or Occupational Illness
LS-210 Rev. Oct. 1998

BulletNotice of Controversion or Right to Compensation
LS-207 Rev. June 1997

BulletNotice of Employee's Injury or Death
LS-201 Rev Jan 1999

BulletNotice of Final Payment or Suspension of Compensation Payments
LS-208 Rev. June 1998

BulletPayment of Compensation Without Award
LS-206 Rev June 1997

BulletPhysician's Report on Impairment of Vision
LS-205 Rev Oct 1998

BulletPre-Hearing Statement
LS-18 Rev June 1997

BulletReport of Earnings
LS-200 May 1998

BulletReport of Injury Experience of Self-Insured Employer
LS-274 Rev. May 1998

BulletRequest for Examination and/or Treatment
LS-1 Rev May 1998

BulletRequest to Employee for Wage Earnings Information
LS-426 Rev. May 1998

Work Capacity Evaluation
BulletCardiovascular/Pulmonary Conditions
OWCP-5b Rev October 2001

BulletMusculoskeletal Conditions
OWCP-5c Rev October 2001

BulletPsychiatric/Psychological Conditions
OWCP-5a Rev October 2001

Occupational Safety and Health Administration (OSHA)
BulletLog and Summary of Occupational Injuries and Illnesses
OSHA 200

BulletSupplemental Record of Occupational Injuries and Illnesses
OSHA 101

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