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

This form is used for filing a workers' compensation claim in California. It is available in both English and Korean and helps injured workers seek benefits for work-related injuries.

This Form is used for submitting the Annual Report of Adjusting Locations in California. It is required for businesses operating as adjusting locations in the state.

This form is used for filing a complaint against a Qualified Medical Evaluator (QME) in California.

This document is used in California to provide proof that a legal document has been served by mail.

This document is a separator sheet used in California for organizing documents.

This document is a petition used in California to seek discrimination benefits under Labor Code Section 132a. It is used by employees who believe they have been subject to discriminatory treatment in the workplace.

This form is used for reporting and verifying cases of serious and willful misconduct by an employer in the state of California. It allows employees to file a complaint and provide evidence of any unethical or illegal actions by their employer.

This document is a declaration form used in California labor cases. It is specific to Labor Code Section 4906(H) and is used for a specific purpose related to labor law.

This Form is used for declaring fees for services in the state of California.

This form is used for petitioning the California Division of Workers' Compensation for the commutation of future payments.

This document is a subpoena form used in California for the purpose of obtaining documents or records.

This form is used for issuing a subpoena in a workers' compensation case in California.

This form is used for petitioning for permission to negotiate a Section 3201.7 labor-management agreement in California.

This Form is used for applying for Independent Medical Review in California.

This document is used for notifying patients about their appointment with a Qualified Medical Evaluator (QME) in California.

This Form is used for notifying the parties involved in a workers' compensation case in California about the unavailability of a Qualified Medical Examiner (QME).

This document is used for reapplying to be a Qualified Medical Evaluator in California.

This document is a request for an extension on the time frame to submit a QME/AME report in the state of California.

This document is used for providing proof that an additional panel has been represented during a legal proceeding in California.

This document is used for requesting a factual correction of an unrepresented panel QME report in California.

This document is used to provide proof that a replacement panel has been represented in California.

This type of document is used for requesting a panel of qualified medical evaluators in California for employees without legal representation.

This document is used to provide proof of service for an unrepresented additional Qualified Medical Evaluator (QME) panel in California.

This document is used to prove that a replacement panel in a California legal case has been served to all parties involved, particularly when one party is not represented by an attorney.

This Form is used for applying for discretionary payments from the Uninsured Employers' Fund in California.

This form is used for injured workers in California whose injuries occurred on or after 1/1/13. It is a supplement job displacement voucher form that provides financial assistance for retraining or skill enhancement. The form is available in Chinese.

This document is a form used in California for securing a Supplementary Intransferable Voucher for the Loss of Job due to Injuries on or after January 1, 2013.

This Form is used for supplementary non-transferable voucher for loss of work due to injuries incurred between Jan 1, 2004 and Dec 31, 2012 in California.

This form is used for California employers to report occupational injuries or illnesses suffered by their employees.

This Form is used for the Back-to-Work Supplement Program application in California for Spanish speakers.

This form is used for applying to the Return-To-Work Supplement Program in California. This program provides financial assistance to eligible workers who have suffered a permanent disability due to a work-related injury.

This form is used for applying for discrimination benefits under Labor Code Section 132a in California. It is a verification form that requires the applicant to provide relevant information and evidence to support their claim.