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

This form is used for petitioning the court in California to appoint a guardian ad litem and trustee.

This form is used for verifying the information regarding the petition for commutation of future payments in the state of California.

This document is used for filing a petition in California to request the commutation of future payments for workers' compensation benefits.

This form is used for reporting the first occurrence of an occupational injury or illness in California. It is filled out by the doctor to provide detailed information about the incident, including the nature of the injury or illness, its cause, and the treatment provided.

This document is used for reporting chiropractic or acupuncture personal injuries in California.

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

This Form is used for predesignating a personal physician in the state of California.

This document is used for verification purposes in the state of California. It may be requested by employers, government agencies, or other organizations to confirm your identity or other information.

This form is used for evaluating the performance of an Administrative Director in California.

This document is used for summarizing the findings of a Qualified Medical Evaluator in unrepresented injured employee cases in California.

This form is used for requesting a qualified medical evaluator panel for unrepresented employees in California.

This Form is used for requesting a Qualified Medical Evaluator (QME) panel under Labor Code 4062.2 in California. It is specifically for injuries that occurred prior to January 1, 2005 and when the injured person is represented by an attorney.

This document is for unrepresented employees in California who are seeking a Qualified Medical Evaluator (QME) panel. It provides instructions on how to request the panel and guides the employee through the process.

This document is used for submitting a pre-trial conference statement in California workers' compensation cases.

This form is used for requesting an expedited hearing (trial) in the state of California.

This document is a petition for California residents seeking benefits due to serious and willful misconduct by their employer. It is filed under Labor Code Section 4553.

This form is used to notify the Workers' Compensation Appeals Board in California of the dismissal of an attorney in a workers' compensation case.

This document is used for verification of serious and willful misconduct by an employer in accordance with Labor Code Section 4553 in California. It is a legal form for reporting and addressing such misconduct.

This Form is used for Employee's Disability Questionnaire in California.

This form is used for petitioning to change your primary treating physician in California's workers' compensation system.

This type of document is a supplemental job displacement non-transferable voucher form for injuries occurring in California after January 1, 2013. It is specifically for Chinese speakers.

This form is used for disclosing the reimbursement rate of a contract in California.

This document is a form used in California for third party compromise and release. It is used to settle any disputes between the injured worker, employer, and the workers' compensation insurance carrier.

This document is used in California for submitting stipulations along with a request for an award in a workers' compensation case.

This form is used for employers in California to report occupational injuries or illnesses to the relevant authorities.

This form is used for the verification process required before filing a lien claim in California. It ensures that the claimant has valid grounds to file the lien and provides supporting documentation.

This document is used for filing an appeal of a decision made by the Administrative Director in the state of California.

This document is a guide provided by the Information & Assistance Unit in California for filing a workers' compensation claim. It provides step-by-step instructions on how to fill out the claim form, known as Form I&A1.

This document is used for petitioning to change the location of a legal proceeding to a different venue within the state of California.

This document is used for filing a petition to request penalties in the state of California.

This Form is used for verifying penalties in California and filing a petition for penalties.

This document is used to request a change of location for a legal case in California.