California Executive

Stipulations with request for award DWC WCAB Form 3

This Official Division of Workers’ Compensation form is used to spell out all of the terms and conditions of a stipulated settlement and the workers’ compensation judge uses the final pages of the form to delineate the parameters of the stipulated award.

Stipulation and award and/or order DWC WCAB Form 5

This form is an example of the proper caption for a stipulation and award. The parties waive the provisions of Labor Code §5313 and then specify the stipulations being made.

Application for benefits for serious and willful misconduct of employer

This form is an example of the proper caption for application for benefits for serious and willful misconduct of an employer.

Request for reconsideration of summary rating by the administrative director

This form may be used by an unrepresented employee or his employer to request the Administrative Director determine whether the permanent disability rating issued by the Disability Evaluation Unit should be reconsidered pursuant to Labor Code §4061(k). The request must be submitted within 30 days of receipt of the rating.

Pre-trial conference statement

This form is used to request a pre-trail conference and specifies the facts of the claim, benefits paid to date and the specific issues to be litigated which include employment, insurance coverage, Injury AOE/COE, parts of the body injured, earnings, temporary disability, permanent and stationary date, permanent disability, apportionment, occupation and group number, need for further medical treatment, liability for self procured medical treatment, liens, attorney fees and other issues.

Petition to reopen DWC WCAB Form 42

This form is an example of the proper caption for a petition to reopen a award for new and further disability.

Petition for Reconsideration DWC Form 45

This Official Division of Workers’ Compensation form is used to initiate reconsideration of a order, decision or award. The form spells out the statutory grounds for seeking reconsideration: (1) the board acted in excess of its powers, (2) the order, decision or award was procured by fraud, (3) evidence does not justify the findings of fact, (4) petitioner has discovered evidence material to him which he could not with reasonable diligence have discovered and produced at the hearing.

Petition for commutation of future payments DWC WCAB Form 49

This Official Division of Workers’ Compensation form is used when an injured worker pursuant to Labor Code §5100 request a commutation of an award to either: (1) all future payments be commuted to a lump sum or (2) sufficient final weekly payment be commuted to produce a specified sum. The applicant must specify the reasons for the request for commutation.

Petition for change of primary treating physician DWC form 280

This Official Division of Workers’ Compensation form is used when an injured worker petitions to change the primary treating physician in accordance with Labor Code  §4603 and Title 8 California Code of Regulations §9786.

Petition for appointment of guardian ad litem and trustee DWC WCAB Form 8

This form is used when minors or incompetents require a guardian ad litem and trustee to prosecute a workers’ compensation claim and to receive and receipt for the benefits awarded or voluntarily funded.

Objection to treating physician's recommendation for spinal surgery DWC Form 233

This Official Division of Workers’ Compensation form as revised May 2007, is used by an employer, insurance carrier, or claims administrator to object to a treating physician’s recommendation for spinal surgery. The form must be filed within 10 days of the first receipt of the treating physician’s report containing the recommendation and must be served on the parties and the Administrative Director Medical Unit, P.O. Box 71010, Oakland, CA 946132.

Notice and request for allowance of lien DWC WCAB Form 6

This Official Division of Workers’ Compensation form is used by a medical provider to request the Workers’ Compensation Appeals Board to determine and allow a lien in a specified sum against the amount due or which may become payable as compensation to the injured worker. An itemized statement justifying the lien must be attached to the form when served on the parties and filed with the Board.

Notice of employee death DIA 510

Every employer must notify the Administrative Director of the Division of Workers’ Compensation of the death of every employee regardless of the cause of death, except where the employer had actual knowledge or notice that the deceased employee left a surviving minor child.

Minutes of hearing/order/order and decision on request for continuance/order taking off calendar/notice of hearing

This form is used by the Workers’ Compensation Judge to record the actions taken during a hearing. The form is signed by the Workers’ Compensation Judge and is serviced with the Minutes of Hearing on all parties.

Medical mileage expense form in English/Spanish

If an employee has to travel to obtain medical treatment for a work injury, the employee is entitled to repayment of travel expenses at the current rate of 48.5 cents per mile and related expenses for parking, tolls, etc. This form is used to claim such reimbursement.

Notice of dismissal of attorney DWC WCAB Form 37

This Official Division of Workers’ Compensation form is used is used by a party to notify the Workers’ Compensation Appeals Board that the party has dismissed their attorney of record and requests that all further documents be served not on the former attorney but upon the party dismissing the attorney.

Declaration of readiness to proceed - expedited hearing (trial) DWC WCAB Form 4

This Official Division of Workers’ Compensation from must be used when a party is requesting an expedited hearing in accordance with Labor Code §5502(b) and AD Rule 10136. An expedited hearing may be had for the following issues: (1) entitlement to medical treatment per Labor Code §4600, )2) entitlement to temporary disability or disagreement on the amount of temporary disability, (3) appeal from a determination of the Rehabilitation Unit finding entitlement to or terminating liability for vocational rehabilitation service, and (4) entitlement to compensation disputed because of disagreements between the employers and/or carriers.

Declaration of readiness to proceed DWC WCAB Form 9

This Official Division of Workers’ Compensation from must be used when a party is ready to proceed to hearing on the issues specified in the declaration. This party filing the declaration must state that discovery on the issued specified in the declaration has been completed and all medical report in their possession have been filed and served in accordance with the Workers’ Compensation Appeals Boar Practice and Procedure Manual. Any objection to the proceedings requested by the declaration must be filed and served within 10 days after service of the declaration in accordance with WCAB Rule 10416.

Request for consultative rating(2)

This form is filed with the WCJ requesting a consultative rating. The request must have attached to it all of the medical reports relevant to the injury being rated.

Compromise and release DWC WCAB Form 15

This Official Division of Workers’ Compensation form must be used to spell out all the terms and conditions of a settlement of a workers’ compensation claim. The form must be presented to the Workers’ Compensation Appeals Board for approval by a WCJ. The settlement reached by using this form may affect other benefits the injured worker is receiving or may be entitled to receive in the future from sources other than workers’ compensation, including but not limited to Social Security, Medicare and long-term disability.

Application for adjudication of claim DWC WCAB Form 1

Filing this application begins the formal proceedings against the employer named in the application. All blanks must be completed. The form must be served in accordance with Labor Code §5501 and §10500 of the Workers’ Compensation Appeals Board Rules of Practice and Procedure.

Application for discrimination benefits pursuant to Labor Code section 132(A)

This form is an example of the proper caption for application for discrimination benefits pursuant to Labor Code §132a.

Appeal from determination and order of the Rehabilitation Unit

This form is an example of the proper caption for an appeal from a determination and order of the Rehabilitation Unit.

Workers' compensation claim form DWC 1

This Official Division of Workers’ Compensation form is known as the Workers’ Compensation Claim form and Notice of Potential Eligibility. The form is filled out by the injured employee who submits it to the employer. The form identifies the employee, the description of the injury and part of body injured. The employer is required to date the form on receipt and provides copies to its insurance carrier or claims administrator and to the employee within one day of receipt of the form from the injured employee.

Information guidelines for submission of settlement documents

This document spells out guidance for submission of settlement documents including Compromise and Releases and Stipulations requesting Awards.

Utilization review complaint form DWC UR Form 1

The utilization review process is governed by Labor Code §4610 and regulations issued by the Division of Workers’ Compensation. (See Title 8, California Code of Regulations §97.92.6 et. seq.) Medical providers, injured workers and others who believe the utilization review process is being used not in compliance with applicable regulations my use this form to file a complaint with the Division of Workers’ Compensation.

Complaint form and information

This form is used to file a complaint about a workers’ compensation administrative law judge pursuant to Labor Code §123.6 and Title 8  California Code of Regulations §9727.1. The form should be mailed to: Department of Industrial Relations, Workers’ Compensation Ethics Advisory Committee, P.O. Box 420603, San Francisco, CA 94142-0603.

Notice of personal chiropractor or personal acupuncturist DWC Form 9783.1

This form is used to notify an employer of the personal chiropractor or personal acupuncturist to whom the injured worker wishes to transfer treatment to.

Notice of pre-designation of personal physician DWC Form 9783

This form is used to pre-designate a medical doctor (M.D.) or osteopathic medicine (D.O.) or medical group, if the employer offers group medical coverage, the doctor is the injured worker’s regular physician and prior to the injury the doctor agrees to treat the worker for work-related injuries and illnesses.

Request for reimbursement of accommodation expenses DWC-AD 10005

This form is required by Title 8, California Code of Regulations §10005 for an employer to request reimbursement of accommodation expenses.

Notice of offer of regular work DWC-AD 10003

This form is required by Title 8, California code of Regulations §1003 to make an offer of regular work.The employer must specify all of the details that properly describe the work being offered.

Notice of offer of modified or alternative work DWC-AD 10133.63

This form is used to offer modified or alternative work. The employee has 30 days to accept or reject the offer of modified or alterative work. Regardless of whether the offer is accepted, the remainder of permanent disability payments may be decreased by 15%. If the employee fails to respond in 30days or rejects the job offer, the employee may under certain circumstance be found ineligible for supplemental job displacement benefits.

How to file a complaint with the Audit Unit DWC-AU-905

This document outlines the procedures to be followed in filing a complaint with the Audit Unit.

Audit referral form DWC-AU-906

This form is used to report a complaint providing specific information about late payment of temporary disability or permanent disability indemnity, failure to pay temporary disability or permanent disability indemnity, of failure to provide vocational rehabilitation services.

Request for dispute resolution before the administrative director DWC-AD 10133.55

This form is used to request dispute resolution by the administrative director for disputes relating to the supplemental job displacement benefit for injuries occurring on or after 1/1/04.

Notice of offer of modified or alternative work DWC-AD 10133.63(2)

This form is used to offer modified or alternative work. The employee has 30 days to accept or reject the offer of modified or alterative work. Regardless of whether the offer is accepted, the remainder of permanent disability payments may be decreased by 15%. If the employee fails to respond in 30days or rejects the job offer, the employee may under certain circumstance be found ineligible for supplemental job displacement benefits.

Supplemental job displacement nontransferable training voucher DWC-AD 10133.57

This non transferable training voucher may be used for tuition fees, books, and other expenses required by a state approved or accredited school that the employee enrolls in for purposes of education related retraining or skills enhancement, or both.

Petition for permission to negotiate a section 3201.7 labor-management agreement DWC Form RGS-1

This form is used to provide information to the Administrative Director for the purpose of obtaining a letter from the Administrative Director advising a union and employer or group of employers of their eligibility to enter into negotiations for the purpose of reaching an agreement on a labor management agreement authorized by Labor Code §3201.7.

Primary treating physician's permanent and stationary report – 1997 DWC Form PR-3

This form is required to be used for ratings prepared pursuant to the 197 Permanent Disability Rating Schedule and the AMA Guides to Evaluation of Permanent Impairment. It is designed to be used by the primary treating physician to report initial evaluation of permanent impairment to the claims administrator.

Primary treating physician's permanent and stationary report -2005 DWC Form PR-4

This form is required to be used for ratings prepared pursuant to the 2005 Permanent Disability Rating Schedule and the AMA Guides to Evaluation of Permanent Impairment. It is designed to be used by the primary treating physician to report initial evaluation of permanent impairment to the claims administrator.

Treating physician's determination of medical issues IMC Form 81556

Primary treating physician's progress report DWC Form PR-2

This report form is used by the primary treating physician to make periodic reports including change in treatment plan, release form care, change in work status, need for referral or consultation, response for request for information change in patient’s condition, need for surgery or hospitalization, request for authorization or other actions or request.

Settlement of prospective vocational rehabilitation services RU 122

This Rehabilitation Unit form is used to record the agreement between the employee and employer to settle prospective rehabilitation services for injuries on or after 1/1/03.

Request for conclusion RU 105

This Rehabilitation Unit form is used to request the Rehabilitation Unit’s approval of conclusion of retaliation services before 1/1/90/ For injuries on or after 1/1/90 use Notice of Termination of Rehabilitation Services (SWC RU-105)

Rehabilitation plan RU 102

This Rehabilitation Unit form documents the objective and methods to be used to implement a proposed rehabilitation plan. The claims administrator submits the form to the Rehabilitation Unit at the time the plan is completed.

Progress report RU 121

This Rehabilitation Unit form is used to report the progress of the employee who is receiving vocational rehabilitation services. The repot is submitted once a month unless otherwise agreed to.

Notice of termination RU 105

This Rehabilitation Unit form is used to notify the employee of the employer’s termination of liability to provide rehabilitation serviced. It is submitted pursuant to Labor Code §4644(a) within 10 days of the circumstances set forth in the form.

Notice of offer of modified or alternate work RU 94

This Rehabilitation Unit form documents an offer of modified or alternate work by the employer at the time of the injury. The form is also used to document the acceptance or rejection of the modified or alternate work by the injured employee.

Evaluation summary RU 120

This Rehabilitation Unit form is used to document the findings and recommendations of the Qualified Rehabilitation Representative who conducted the initial vocational rehabilitation evaluation. It should be submitted not later than 30 days from the completion of the initial interviews unless otherwise agreed to.

Description of job duties RU 91

This Rehabilitation Unit form is used to obtain a job description which is forwarded to the employee’ s treating physician when an injury or illness results in disability exceeding 90 days. The form is prepared and submitted by the  employer’s claims administrator.

Declination for dates of injury 1/1/90 - 12/31/93 RU 107

This Rehabilitation Unit form is used by an employee to decline vocational rehabilitation services f0llowing notification of medical eligibility. The form is signed by the employee or his representative. The employer submits the form to the Rehabilitation Unit with a properly completed Notice of Termination of Vocational Rehabilitation Services (DWC RU-105).

Treating physician report of disability RU 90

This Rehabilitation Unit form is designed to allow early identification of an employee’s potential need or vocational rehabilitation services. The employer’s claims administrator of the Qualified Rehabilitation Representative must solicit the treating physician’s opinion concerning the employee’s ability to return to previous employment.

Employee's request for informal permanent disability rating DEU 200

This form is completed by the injured worker and sent to the Disability Evaluation Unit to request an Informal Permanent Disability Rating. It is not a request for hearing and does not prevent the operation of the statute of limitations.

Request for consultative rating

This form made be used to request a consultative rating either on a mail-in or walk-in bases. The request must have attached to it the medical reports for which the rating is requested.

Request for summary rating determination (of AME's or QME 's report) DEU 101

This form is used in the case of an unrepresented injured worker to request a summary rating by the administrative director of a Agreed Medical Evaluator or Qualified Medical Evaluator’s  report.

Request for summary rating determination (of primary treating physician's report) DEU 102

This form is used in the case of an unrepresented  injured worker to request a summary rating by the administrative director of a primary treating physician’s report.

Request for informal rating (by insurance carrier or self-insurer) DEU 201

This form letter sets forth the necessary information required for an insuer or self-insured to request an informal disability rating.

Notice of options following disability rating DEU 110

This document prepared by the Disability Evaluation Unit outlines the options and procedures available to the unrepresented injured worker following receipt of a disability rating.

Employee's permanent disability questionnaire DEU 100

This form is completed by the injured worker and is used to aid the physician determining permanent disability.

Apportionment DEU 105

This form letter is used by the Disability Evaluation Unit to transmit to the presiding WCJ medical evaluation reports indicating that part or all of the permanent disability may be subject to apportionment pursuant to Labor Code §§4663 and 4664 and requests the presiding WCJ to return the case to the assigned WCJ to determine whether apportionment is consistent or inconsistent with the law.

Request for reconsideration of summary rating by the administrative director DEU 103

This form is used in the case of an unrepresented injured worker to request a summary rating by the administrative director of a Qualified Medical Evaluator or Agreed Medical Evaluator’s report.

Objection toObjection to treating physician's recommendation for spinal surgery DWC 233 treating physician's recommendation for spinal surgerySSSOForm233

This form revised in May 2007 is used by the employer/insurance carrier to object to the treating physician’s recommendation for spinal surgery.

Application for spinal surgery second opinion physician list DWC 232

This form is used pursuant to Title 8, California Code of Regulations §9788.31 to apply for a spinal surgery physician second opinion list. The form should be sent to the Division of Workers’ Compensation, P.O. Box 71010, Oakland, CA 94612.

Notice of medical provider network plan modification §9767.8 DWC Form 9767.8

This form is mandatory as specified in Title 8, California Code of Regulations §9767.8 and is used to request a modification of an existing medical provider plan.

Physician contract application DWC Form 9768.5

This form mandated by Title 8, California Code of Regulations §9768.5 is used by doctors who want to become Independent Medical Reviewers.

Cover page for medical provider network application DWC from 9767.4

This form is required by Title 8, California Code of Regulations §9767.4 and contains all the pertinent data for an application to become a medical provider network. It should be submitted to Division of Workers’ Compensation–MPN Application, P.O. Box 71010, Oakland, CA 94612.

Independent medical review application

This form is mandatory as specified in Title 8 California Code of Regulations §9768.10 and is to be used to request  pursuant to Labor Code §4616.4 for the Administrative Director to set an Independent Medical Review within 30 days of the receipt of the application.

Sample initial written employee notification re: Medical provider network

This form mandated by Title 8, California Code of Regulations §9767.12 is used to notify an employee of the employer’s participation in a Medical Provider Network and provides the employee with all the necessary information needed to access the network.

Qualified medical evaluator letter IMC Form 108

This form letter is used by the Division of Workers’ Compensation–Medical Unit to inform an unrepresented injued worker of the selection process to choose a Qualified Medical Evaluator. The WME is only use when there is a dispute over the primary treating physician’s report.

Qualified or agreed medical evaluator's findings summary IMC Form 111

A QME or AME is required by Labor Code §4061 to summarize the medical finding from a comprehensive medical-legal evaluation on this form.

Qualified medical evaluator fees IMC Form103

This form letter is sent by the Industrial Medical Council pursuant to Labor Code §139.2(a) and Title 8, California Code of Regulations §18 setting forth the annual fees required to be paid by physicians appointed or re-appointed as Qualified Medical Evaluators.

Qualified medical evaluator exam packet - Oct. 27, 2007

This form is to be used to submit an Application for Appointment as a QME and Registration for the QME Competency examination on October 27, 2007.

Qualified medical evaluator complaint form

Qualified medical evaluator appointment notification form IMC Form 110

This form is used to satisfy the requirement by the Industrial Medical Council that the employer/insurer and employee be notified of the appointment as a Qualified Medical Evaluator within 5 days of having schedule the injured worker to be seen for a comprehensive qualified medical evaluation.

QME/AME time frame extension request IMC Form 112

This form is required for a AME/AME timeframe extension request for late reporting on an accepted claim. The form must be sent to the Industrial Medical council 5 days before the QME/AME report is due and must be served on the parties. The form should be sent to the Industrial Medical Council, Executive Medical Director, P.O. Box 8888, San Francisco, CA 94128-8888.

Notice of qualified medical evaluator unavailability IMC Form 109

This form is to be used by a Qualified Medical Evaluator Panelist to report his/her unavailability for assignment for a period of 14 days or more.

How to request a qualified medical evaluator IMC Form 105

This document outlines the procedure for an injured worker who is not represented by an attorney to request a qualified medical evaluator.

Treating physician's determination of medical issues IMC Form 81556(2)

The use of this form is optional. The primary treating physician may use it for interim/supplemental reports, at the completion of treatment, patient’s discharge or when the patient is permanent and stationary.

Application for accreditation or re-accreditation as education provider IMC Form 118

This form is to be used to obtain accreditation of re-accreditation as a medical education provider.

Request for qualified medical evaluator IMC Form 106

This form is used to request a panel qualified medical evaluator by an injured worker not represented by an attorney. If the Industrial Medical Council does not issue a QME panel within 15 working days after the request is received by the IMC, the injured worker is entitle to select a QME of his/her choice. The form should be sent to the Industrial Medical Council, Executive Medical Director, P.O. Box 8888, San Francisco, CA 94128-8888.

Reappointment application as qualified medical evaluator IMC Form 104

This form is used by a Qualified Medical Evaluator to spell out his/her qualifications for reappointment as a qualified medical evaluator. The form should be sent to Industrial Medical Council, Executive Medical Director, P.O. Box 8888, San Francisco, CA 94128-8888.

Report of suspected medical care provider fraud DWC Form SMBFR 1115

Labor Code §3823 requires any insurer, self-insured, third party administrator, WCJ, audit unit, attorney or other person that believes a fraudulent clam has been made by a person providing medical care to report the apparent fraudulent claim to the Division of Workers’ Compensation using this form.

Request for authorization number form DWC Form AD 3

This form is used to request to request a DWC authorization number to facilitate streamlined access to WCAB records. The request should be mailed  to DWC Public Records Office, P.O. Box 420603, San Francisco, CA 94142 or by fax (510)286-7163.

Request for Public records

This form is used to request public information from the Division of Workers’ Compensation. The form may be submitted by e-amail: DWCPAR@dir.ca.gov or by fax (916)322-3470.

Employer's report of occupational injury or illness DLSR 5020

California law requires employers within five days of knowledge of every occupational injury or illness which results in lost time beyond the date of incident or requires medical treatment beyond first aid.

Doctor's first report of occupational injury or illness DLSR 5021

This is the Division of Labor Statistics and Research form that must be used by the treating physician to report the circumstances under which the industrial injury was sustained, the initial treatment rendered and work status of the injured worker. This form must be completed within 5 days of the initial treatment for every occupational injury. Failure to timely file this report may result in assessment of a civil penalty.

Arbitration Application

This document may be used to apply to be appointed an arbitrator by the Division of Workers' compensation. The qualifications to be an arbitrator are set forth in Labor Code section 5270.5(a).

Request for accommodations by persons with disability DWC Form 5

This Division of Workers’ Compensation form should be used by an employee with disabilities to request accommodation and must specify the date accommodations are needed, the impairment necessitating accommodation, and the type of accommodation being requests.

Notice of employee death DIA 519

Every employer must notify the Administrative Director of the Division of Workers’ Compensation of the death of every employee regardless of the cause of death, except where the employer had actual knowledge or notice that the deceased employee left a surviving minor child.