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 10214 (a) stipulations with request for award | $12.99 | |
DWC Form 5 Request for Accommodation by Persons with Disabilities | $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 |