Workers' Compensation Forms
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.
Read about pre-designation
Workers' Compensation Claim Form (DWC-1)
This form is required to initiate a claim for workers' compensation benefits.
Read about the DWC-1 form
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.
Read about the 10133.57 voucher
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.
Read about the 10133.32 voucher
Medicine Record Form
This is a form created by GEKLaw for injured workers to utilize to keep track of their medication.
Read about the medicine record
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.
Read about mileage forms
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.
Read about utilization review
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.
Read about the IMR application
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).
Read about the IMR notice
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.
Read about IMR determinations
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.
Read about benefit letters
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.
Read about adjudication
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.
Read about medical authorization
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.
Read the glossary of terms
Video Intro to Workers' Compensation Forms
Workers' Compensation Attorney Erika L. Vargas discusses the many forms involved in a Workers' Compensation case.
Watch the video introFact Sheets
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.
Read about forms in other languages
