California Department of Industrial Relations Forms

This form is used for reporting occupational injuries or illnesses by doctors in California.

This form is used for notifying the State of California about the death of an employee.

This form is used for notifying appointments related to Qualified Medical Evaluations (QME) in the state of California.

This Form is used for a Compromise and Release agreement in the state of California. It is a legal document that resolves disputes and settles claims between two parties.

This form is used for applying for accreditation or re-accreditation as an education provider in California.

This form is used for assessing safety and health programs in California. It helps evaluate and identify areas that need improvement to ensure a safe working environment.

This checklist is used in California to assess potential hazards in a specific area or workplace. It helps identify and prevent potential risks to ensure safety and compliance with regulations.

This form is used for reporting a physician's evaluation and recommendation for an individual's return to work in California, along with any necessary voucher information.

This type of document is used to file an initial report or claim with the California Division of Labor Standards Enforcement (DLSE). It is often filled out by employees who have a dispute or complaint related to their employment.

This form is used to request a panel of qualified medical evaluators in California for medical evaluations related to workers' compensation claims. It helps injured workers select a medical evaluator for their case.

This form is used for predesignating a personal physician in the state of California. It allows individuals to designate a specific doctor who will provide medical treatment if they are injured on the job.

This Form is used for filing a worker complaint related to public works projects in California.

This document is used in California to compel the production of documents or other tangible evidence for a legal proceeding.

This form is used for applying for a Certificate of Consent to administer workers' compensation self insurance claims in the state of California. It is required for organizations that want to handle their own workers' compensation claims instead of purchasing insurance through an insurance company.

This document is for an indemnity agreement and power of attorney in California. It allows one party to provide financial protection to another party and grants the authority to act on their behalf.

This type of document is used for submitting an interim application for private or public projects in the state of California.

This form is used for applying for a permanent certificate of consent to self-insure for interim self-insurer in the state of California. It allows companies to self-insure their workers' compensation claims.

This form is used for authorizing a corporation to apply for a certificate of consent to self-insure workers' compensation liabilities in the State of California.

This Form is used for agreements and undertakings related to security deposits in California.

This document is used for guaranteeing workers' compensation liabilities in the state of California.

This Form is used for authorizing a corporate resolution to apply for a Certificate of Consent to self-insure workers' compensation liabilities in the State of California.

This Form is used for agreeing and undertaking the security deposit in California. It outlines the terms and conditions related to the security deposit for a rental property.

This form is used for applying for an Affiliate Certificate of Consent to Self-insure as a Member of a Group Self-insurer in California.

This document is used for applying for a Certificate of Consent to self-insure as a private employer self-insurer in the state of California.

This Form is used for the agreement of assumption and guarantee of workers' compensation liabilities for group and affiliate members in California.

This document is a report of the transfer of records in the state of California. It is used to document the movement of important documents or information from one location to another.

This Form is used for public agencies in California to apply for a Certificate of Consent to self-insure as an employer.

This form is used for submitting an interim application for becoming a group affiliate member in California.

This form is used for applying for a certificate of consent to self-insure as a group self-insurer in California. It is intended for groups who want to self-insure for workers' compensation coverage.

This document is used to file an initial report or claim with the DLSE (Department of Labor Standards Enforcement) in California. This specific form is in Tagalog.

This Form is used for filing a claim by public works employees in California.

This form is used for filing an Equal Pay Act complaint in California. It allows individuals to report instances of unequal pay based on gender or other protected characteristics.

This form is used for filing a complaint of retaliation in the state of California. It allows individuals to report any retaliation they have experienced as a result of taking certain protected actions, such as engaging in protected activities or making a complaint against their employer.

This form is used as a legal document and filled out by a treating physician of an employee with a work-related injury or illness to request authorization of special medical treatment, services, and procedures.

This Form is used for applying to take the self insurance administrator's examination 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 requesting stipulations with a request for an award in a death case in California's DWC-CA system.

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

This document resolves the agreement for a parent assuming and guaranteeing responsibility in California. It clarifies the terms and obligations involved in the parental assumption and guarantee.