Find the Right California Workers' Comp Form

Throughout the course of any Workers’ Compensation case, an injured worker will receive a wide variety of forms, regarding everything from medical treatment to financial benefits. It is extremely important to read the forms carefully, and contact an attorney to confirm what action, if any, needs to be taken. Keep in mind that many of these forms include strict timelines that must be met.

Workers' Compensation Forms

Pre-designation Form for workers compensation

Pre-Designation Form

This is a form that was created by the Division of Workers’ Compensation, consistent with Labor Code Section 4600(d), to allow an injured worker to predesignate a physician prior to an industrial injury.

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Claim Form for DWC-1: Workers Comp Claim Form

Workers’ Compensation Claim Form (DWC-1)

This form is required to initiate a claim for workers’ compensation benefits.

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CA Supplemental Job Displacement FormForm DWC-AD 10133.57

Form DWC-AD 10133.57
Supplemental Job Displacement Form

If an injured worker is not accommodated and returned to work by his or her employer after an injury, then the injured worker can qualify for this return to work assistance benefit.

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Form DWC - AD 10133.32 For Injuries Occuring on or after 1/1/13.  Workers Comp Forms.

Form DWC - AD 10133.32
For Injuries Occuring on or after 1/1/13

If an injured worker is not accommodated and returned to work by his or her employer after an injury, then the injured worker can qualify for this return to work assistance benefit.

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California Medicine Record Form

Medicine Record Form

This is a form created by GEKLaw for injured workers to utilize to keep track of their medication.

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Medical Mileage Expense Form

Medical Mileage Expense Forms

Workers injured on the job are entitled to reimbursement for medical mileage, which includes for example transportation to and from the treating physician, physical therapy, and the pharmacy.

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Utilization Review Communication Form

Utilization Review Communication

When a treating physician submits a request for medical treatment, the insurance company more often than not, will submit the medical treatment request to a Utilization Review company

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CA Independent Medical Review (IMR) Application

Independent Medical Review (IMR) Application

It is required that this form be filled out, and sent to the injured worker with a Utilization Review denial letter.

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Notice of Assignment of Independent Medical Review (IMR)

Notice of Assignment of Independent Medical Review (IMR)

The administrative director (AD) designated a company entitled Maximus to conduct all of the Independent Medical Review (IMR).

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Sample Determination of Independent Medical Review (IMR)

Sample Determination of Independent Medical Review (IMR)

The final determination for a “regular” IMR review is 30 days of receipt of the IMR Application and supporting documentation.

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Sample Benefit Letters – Delay, Deny, Accept

Sample Benefit Letters – Delay, Deny, Accept

After an Employee Claim Form (link to above) is filed, within 14 days an injured worker is to receive a benefit letter accepting, rejecting, or delaying the determination of the claim.

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Sample Application for Adjudication of Claim and Notice of Application

Sample Application for Adjudication of Claim and Notice of Application

At the onset of a case, an Application for Adjudication of Claim is filed on behalf of the injured worker.

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Medical Authorization Form

Medical Authorization Form

If you've filed a Workers' Compensation claim, you've undoubtedly received a blank medical records release form from your employer's insurance adjuster.

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Glossary of Terms for California Workers Compensation

Glossary of Terms

This is a list of common terms and phrases that arise in a workers’ compensation case. This list was prepared by California’s Division of Workers’ Compensation.

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Workers Comp Forms Video

Video Intro to Workers' Compensation Forms

Workers' Compensation Attorney Erika L. Vargas discusses the many forms involved in a Workers' Compensation case.

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Fact Sheets

Workers Compensation Form languages

Workers’ Compensation Documents Now Available in Six Languages

With the passing of recent legislation, much of California’s Workers’ Compensation information is now available in six different languages to reflect the cultural diversity of the state.

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