California Department of Industrial Relations - Division of Workers' Compensation Forms

This Form is used for submitting a petition to reopen a verification form in the state of California. It allows individuals to request the reconsideration of their verification status.

This document notifies an individual about a lawsuit that has been filed against them in California.

This form is used for replacing attorneys in workers' compensation cases in California.

This document is used in California to notify injured workers of regular work offers for injuries that occurred between January 1, 2005, and December 31, 2012.

This Form is used for requesting a DWC Authorization Number in California.

This document is used for declaring readiness to proceed to an expedited hearing (trial) in the state of California for a workers' compensation case.

This form is used for filing a Declaration of Readiness to Proceed in a workers' compensation case in California.

This Form is used for California workers who have suffered a work-related injury or illness and are eligible to receive a supplemental job displacement non-transferable voucher.

This form is used for describing an employee's job duties in California. It helps to provide a detailed description of the tasks and responsibilities performed by the employee.

This document is a petition that can be used to appeal the determination made by an Administrative Director's Independent Medical Review in the state of California. It is a formal request to reconsider a decision regarding medical treatment.

This form is used for requesting a refund of filing fees for lien filings in California.

This form is used for obtaining a Supplemental Job Displacement Nontransferable Training Voucher in California for injuries that occurred between January 1, 2004, and December 31, 2012.

This Form is used for reporting the outcome of a lien conference in a workers' compensation case in California.

This document is used for requesting apportionment in the state of California. It is utilized to allocate income between different states or jurisdictions for tax purposes.

This form is used for filing a complaint against a medical provider in the California Medical Provider Network.

This Form is used for filing a petition in California to suspend or revoke a Medical Provider Network (MPN). It is part of the DWC Form 9767.17.5 and is specifically designated as Part A of the petition.

This form is used for filing a petition to suspend or revoke a Medical Provider Network (MPN) in California. It is a necessary step to report any concerns or issues with an MPN.

This Form is used for applying or renewing accreditation as an education provider in California. It provides instructions on how to complete the QME Form 118 Application.

This Form is used for requesting stipulations with a request for an award in a death case in California's DWC-CA system.

This form is used for supplementing the minutes of a hearing in the state of California. It provides additional information to ensure accuracy and completeness of the hearing record.

This Form is used for submitting a notice and request for allowance of a lien in the state of California through the Division of Workers' Compensation (DWC) and the Workers' Compensation Appeals Board (WCAB).

This form is used for submitting a Compromise and Release - Dependency Claim in the state of California.

This form is used for filing a workers' compensation claim in California. It is available in both English and Spanish.

This document is for designating a personal doctor in California. It is available in Spanish.

This form is used for primary treating physicians in California to report on the permanent and stationary status of the injured worker.

This form is used for reporting the permanent and stationary status of the primary treating physician in California workers' compensation cases.

This Form is used for filing a petition in California to appoint a guardian ad litem and trustee.

This form is used for filing a petition to reopen a workers' compensation case in the state of California.

This document is used for submitting an arbitration claim in California. It is a form that needs to be filled out and submitted to initiate the arbitration process.

This form is used for registering for the QME Competency Examination in California.

This Form is used for reporting personal chiropractic or personal acupuncture services in California.

This form is used for requesting a summary rating determination of the primary treating physician report in California. It helps with evaluating the rating for work-related injuries and determining the appropriate benefits for the injured worker.

This form is used for requesting a consultative rating in the state of California.

This form is used in California to request a reconsideration of the summary rating given by the Administrative Director.

This form is used to respond to an application for adjudication of a claim in the state of California. It allows the respondent to provide their answer to the claim.

This type of document is used in California to petition for the termination of liability for temporary disability indemnity in a workers' compensation case.

This Form is used for filing a workers' compensation claim in California, and is available in both English and Chinese language.