California Division of Workers’ Compensation DWC Forms in Word

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Form Number and Title Price Buy Now
DWC 1 Workers’ Compensation claim Form and notice of potential eligibility $12.99
CA-WC 5020 First Report of Injury/Illness $37.99
Medical mileage expense Form in English/Spanish $12.99
CA DWC-AD 10118-NOTICE OF OFFER OF REGULAR WORK FOR INJURIES OCCURRING BETWEEN 1/1/05 – 12/31/12 $12.99
DWC AD 10133.33-DESCRIPTION OF EMPLOYEE’S JOB DUTIES $12.99
DWC AD 10133.32-SUPPLEMENTAL JOB DISPLACEMENT NON-TRANSFERABLE VOUCHER Form For Injuries Occurring on or After January 1, 2013 $12.99
DWC AD 10133.35-NOTICE OF OFFER OF REGULAR, MODIFIED, OR ALTERNATIVE WORK For injuries occurring on or after 1/1/13 $12.99
DWC AD 10133.53-NOTICE OF OFFER OF MODIFIED OR ALTERNATIVE WORK FOR INJURIES OCCURRING BETWEEN 1/1/04 – 12/31/12 $12.99
DWC AD 10133.55-REQUEST FOR DISPUTE RESOLUTIONBEFORE ADMINISTRATIVE DIRECTOR $12.99
DWC AD 10133.57 $12.99
WCAB
Appeal from determination and order of the rehabilitation unit $12.99
Application for benefits for serious and willful misconduct of employer $12.99
Application for discrimination benefits pursuant to Labor Code section 132(A) $12.99
Medical mileage expense Form in English/Spanish $12.99
Minutes of hearing/order/order and decision on request for continuance/order taking off calendar/notice of hearing $12.99
Pre-trial conference statement $12.99
Request for reconsideration of summary rating to the administrative director $12.99
Notice and request for allowance of lien $12.99
DWC Form 4 Declaration of readiness to proceed-expedited hearing (trial) $12.99
DWC WCAB Form 3 Stipulations with request for award $12.99
DWC WCAB Form 5 Stipulation and award and/or order $12.99
DWC WCAB Form 9 Declaration of readiness to proceed $12.99
DWC WCAB Form 15 Compromise and release $12.99
DWC/WCAB Form 37 Notice of dismissal of attorney $12.99
DWC/WCAB Form 42 Petition to reopen $12.99
DWC/WCAB Form 45 Petition for reconsideration $12.99
DWC/WCAB Form 49 Petition for commutation of future payments $12.99
Carve-out Agreements
DWC DG1 Petition for permission to negotiate a Section 3201.7 labor-management agreement $12.99
Disability Evaluation
DEU 100 Employee’s permanent disability questionnaire $12.99
DEU 101 Request for summary rating determination (of AME’s or QME’s report) $12.99
DEU 102 Request for summary rating determination (of primary treating physician’s report) $12.99
DEU 103 Request for reconsideration of summary rating by the administrative director $12.99
DEU 105 Apportionment $12.99
DEU 110 Notice of options following permanent disability rating $12.99
DEU 200 Employee’s request for in Formal permanent disability rating $12.99
DEU 201 Request for in Formal rating (by insurance carrier or self-insurer) $12.99
Request for Consultative Rating $12.99
Supplemental job displacement benefit
DWC-AD 10133.53 Notice of offer of modified or alternative work-injuries occurring on or after 1/1/04 -effective Aug. 1, 2005 $12.99
DWC-AD 10133.55 Request for dispute resolution before the administrative director-injuries occurring on or after 1/1/04 -effective Aug. 1, 2005 $12.99
DWC-AD 10133.57 Supplemental job displacement nontransferable training voucher Form-injuries occurring on or after 1/1/04 -effective Aug 1, 2005 $12.99
Spinal surgery second opinion
DWC 232 Application for spinal surgery 2nd opinion physician list $12.99
DWC 233 Objection to treating physician’s recommendation for spinal surgery $12.99
Vocational Rehabilitation.
RU 90 Treating physician report of disability $12.99
RU 91 Description of job duties $12.99
RU 94 Notice of offer of modified or alternate work $12.99
RU 102 Rehabilitation Plan $12.99
RU 103 Request for dispute resolution and instructions $12.99
RB 105 Request for conclusion $12.99
RU 105 Notice of Termination $12.99
RB 107 Declination for date of injury’s pre 1/1/90 $12.99
RU 107 Declination for date of injury’s 1/1/90- 12/31/93 $12.99
RU 107A Declination for date of injury’s post 1/1/94 $12.99
RU 120 Evaluation summary $12.99
RU 121 Program report $12.99
RU 122 Settlement of prospective vocational rehabilitation services $12.99
Independent medical review
DWC Form 9768.5 Physician contract application $12.99
Independent Medical Review Application $12.99
Primary Treating Physician Reports
PR-2 Primary treating physician’s progress report $12.99
PR-3 Primary treating physician’s permanent and stationary report (1997 Permanent disability rating schedule) $12.99
PR-4 Primary treating physician’s permanent and stationary report (2005 Permanent disability rating schedule) (7 pages) $412.99
DWC Form 280 Petition for change of primary treating physician $12.99
DLSR Form 5021 Doctor’s first report of occupational injury or illness $12.99
Audit
DWC-AU-906 Audit referral Form $12.99
Medical provider network Forms
DWC Form 9767.4 Cover page for medical provider network application $12.99
DWC Form 9767.8 Notice of medical provider network plan modification §9767.8 $12.99
Fee schedule
DWC Form 15 Election for high cost outlier $12.99
Official medical fee schedule (OMFS) order Form $12.99
Judicial Ethics
Complaint Form and in Formation $12.99