California Workers' Compensation Forms Workers' Compensation Appeals Board Vocational Rehabilitation Disability Evaluation Audit Primary Treating Physician Reports Independent Medical Review Judicial Ethics Managed Care Employee and Employer Forms Qualified Medical Examiner Self Insurance Medical Provider Network U.S Department of Labor Forms Division of Federal Employees' Compensation Division of Longshore and Harbor Workers' Compensation Work Capacity Evaluation Occupational Safety and Health Administration (OSHA)

California Workers' Compensation Forms

Workers' Compensation Appeals Board

Answer

WCAB Form 2 (REV 4/1/90)

Answer Of ___

DIA WCAB 10 (Rev 7/81)

Appeal From Determination and Order of the Rehabilitation Unit

Application for Adjudication of Claim

WCAB Form 1 (REV 2/91)

Application for Adjudication of Claim

DIA WCAB Form 1 REV 7/81

Application for Adjudication of Claim (Death Case)

WCAB Form 1A (REV 2/91)

Application for Benefits for Serious and Willful Misconduct of Employer

Application for Discrimination Benefits Pursuant to labor Code Section 132(A)

Application for Spinal Surgery 2nd Opinion Physician List

DWC Form 232 (12/2004)

Compromise and Release

DIA WCAB FORM 15 (Rev 10/2005)

Compromise and Release (Dependency Claim)

DWC WCAB 16 (Rev 10-92)

Consultative Rating Request

DIA 11

Declaration of Readiness to Proceed

DWC WCAB 9 (Rev 1/1/03)

Declaration of Readiness To Proceed To Expedited Hearing (Trial)

DWC Form 4 (Rev.1/1/03)

Fee Disclosure Statement

DWC Form 3 (Rev. 3/93)

Fee Disclosure Statement (Spanish)

DWC Form 3-S

Information Request Form

WCAB 7A (Rev 5/92)

Information Response Form

WCAB 7B (Rev 5/92)

Minutes of Hearing/Order/Order and Decision on Request for Continuance/Order Taking Off Calendar/Not

Notice of Dismissal of Attorney

DWC WCAB FORM 37 (Rev 8-75)

Notice of Offer of Modified or Alternative Work

DWC-AD-10133.53 (08/05)

Notice Regarding Workers' Compensation Claim

WC-002

Objection to Treating Physicians Recommendation for Spinal Surgery

DWC Form 233 (10/2004)

Order for Submittal to Arbitrator Panel/Agreed Arbitrator

WCAB 33 (New 2/91)

Order Joining Party Defendent

DIA WCAB FORM 53 (Rev 2/75)

Order of Dismissal

DIA WCAB FORM 51 (Rev 12/75)

Petition for Benefits/Penalty

WC 100

Petition for Order Allowing Attorney's Fees

WC 900

Petition for Permanent Disability Rating

DIA WCAB FORM 41 (Rev 11/76)

Petition for Permission to Negotiate a Section 3201.7 Labor-Management Agreement

DWC Form RGS-1 (012004)

Petition for Reconsideration

DWC WCAB FORM 45 (Rev 3-76)

Pre-Trial Conference Statement Section 5502 (d)(3)

Request for Dismissal

DWC WCAB FORM 43 (Rev 3-90)

Request for Dispute Resolution Before the Administrative Director

DWC-AD-10133.55 (08/05)

Stipulation and Award and/or Order

DWC WCAB 5 (Rev 10/2005)

Stipulation and Order Granting Payment of Lien Claim

WC 903

Stipulations with Request for Award

DWC WCAB Form 3 (Rev 10/2005)

Stipulations with Request for Award (Death Case)

DIA WCAB 4 (Rev 2-75)

Substitution of Attorney

DIA WCAB FORM 36 (REV. 10-74)

Supplemental Job Displacement Nontransferable Training Voucher Form

DWC-AD-10133.57 (06/05)

Third-Party Compromise and Release

DIA WCAB FORM 17 (Rev 11/74)

Vocational Rehabilitation

Case Initiation Document

DWC Form RU-101 (12/90)

Description of Employee's Job Duties

DWC Form RU-91 (1/95)

Notice of Termination of Vocational Rehabilitation Services

DWC Form RU-105 (01/03)

Request for Dispute Resolution

DWC Form RU-103 (01/03)

Settlement of Prospective Vocational Rehabilitiation Service

DWC Form RU-122 01/03

Statement of Decline of Vocational Rehabilitation Benefits State of California

DWC Form RB-107 (pre 1/1/90)

Treating Physician's Report of Disability Status State of California

DWC Form RU-90 (12/90)

Vocational Rehabilitation Plan

DWC Form RU-102 (1/03)

Vocational Rehabilitation Progress Report

DWC Form RU-121 (Rev 9/98)

Disability Evaluation

Apportionment

DEU Form 105 (Rev 01/01/05)

Employee's Disability Questionnaire

DEU Form 100 (Rev 06-05)

Employee's Request for Informal Permanent Disability Rating

DIA Form 200 (Rev 2-86)

Notice of Options Following Disability Rating

DEU Form 110 (Rev 06-05)

Request for Consultative Rating Consult Request Form

Rev Feb 2002

Request for Informal Rating By Insurance Carrier or Self-Insurer

Form DWC 201 (Rev 8/90)

Request For Summary Rating Determination of Primary Treating Physician's Report

DEU Form 102 (2/95)

Request For Summary Rating Determination of Qualified Medical Evaluator's Report

DEU Form 101 (Rev 06-05)

Audit

Audit Referal Form

DWC-AU-906 (Rev 08/04)

Primary Treating Physician Reports

Doctor's First Report of Occupational Injury or Illness

Form 5021 (Rev 4) 1992

Primary Treating Physician's Permanent and Stationary Report

DWC Form PR-4 (Rev 06-05)

Primary Treating Physician's Permanent and Stationary Report

DWC Form PR-3 (Rev 06-05)

Primary Treating Physician's Progress Report

DWC Form PR-2 (Rev 06-05)

Independent Medical Review

Independent Medical Review Application

Mandatory Form 4/30/05

Physician Contract Application

DWC Form 9768.5 (Final Regulation April 19, 2005)

Judicial Ethics

Complaint About a Workers' Compensation Administrative Judge

Labor Code Section 123.6 and Title 8, Cal Code Regs Section 9722.1

Employee and Employer Forms

Employer's Report of Occupational Injury or Illness

Form 5020 (Rev7) June 2002

Workers' Compensation Claim Form

DWC-1 Rev. 7/1/04

Qualified Medical Examiner

Request for Qualified Medical Evaluator

IMC Form 106 Rev 4/14/00

Medical Provider Network

Cover Page for Medical Provider Network Application

DWC Mandatory Form Section 9767.4 - 09/15/05

Notice of Medical Provider Network Plan Modification

DWC Mandatory Form - Section 9767.8 - 09/15/05

U.S Department of Labor Forms

Division of Federal Employees' Compensation

Agreement and Undertaking

OWCP-1

Attending Physician's Report

CA-20 Rev. Nov 1999

Claim for Compensation

CA-7 Rev Nov 1999

Claim for Compensation By Parents, Brothers, Sisters, Grandparents, or Grandchildren

CA-5b Rev Jan 1997

Claim for Compensation by Widow, Widower, and/or Children

CA-5 Rev Jan 1997

Claim for Continuance of Compensation Under the Federal Employees Compensation Act

CA-12

Claim for Reimbursement Assisted Reemployment

CA-2231

Claimant Medical Reimbursement Form

CA-915 Feb 1999

Duty Status Report

CA-17 Rev Jan 1997

Evidence Required in Support of a Claim

CA-35

Federal Employee's Notice of Traumatic Injury and Claim for Continuation of Pay/Compensation

CA-1 Rev Apr 1999

Health Insurance Claim Form

Form CMS-1500 (08/05)

Health Insurance Claim Form

HCFA-1500 (12-90), RRB-1500, OWCP-1500

Leave Buy Back Worksheet/Certification and Election

CA-7b June 1996

Medical Travel Refund Request

OWCP-957 Rev Aug 2001

Notice of Law Enforcement Officer's Death

CA-722

Notice of Law Enforcement Officer's Injury or Occupational Disease

CA-721

Notice of Occupational Disease and Claim for Compensation

CA-2 Rev Jan 1997

Notice of Recurrence

CA-2a Rev Sept 1996

Official Superior's Report of Employee's Death

CA-6 Rev Jan 1997

Outline for Otologic Evaluation

CA-1332 Rev Jan 1997

Overpayment Recovery Questionnaire

OWCP-20

Rehabilitation Action Report

OWCP-44

Rehabilitation Maintenance Certificate

OWCP-17

Report of Termination of Disability and/or Payment

CA-3 Rev June 1988

Time Analysis Form

CA-7a June 1996

Uniform Health Insurance Claim Form

UB-92 HCFA-1450

Division of Longshore and Harbor Workers' Compensation

Application for Continuation of Death Benefit for Student

LS-266 Rev. Jan. 2002

Application for Self-Insurance

LS-271 Rev. May 2003

Approval of Compromise of Third Person Cause of Action

LS-33 Rev. Sept 1974

Attending Physician's Supplementary Report

LS-204 Rev May 1998

Certification of Funeral Expenses

LS-265 Rev. May 2002

Claim for Death Benefits

LS-262 Rev. Sept. 1998

Claimant's Statement

LS-267 Rev. May 1998

Employee's Claim for Compensation

LS-203 Rev Sept 1998

Employer's First Report of Injury or Occupational Illness

LS-202 Rev Oct 1998

Employer's Supplementary Report of Accident or Occupational Illness

LS-210 Rev. Oct. 1998

Notice of Controversion or Right to Compensation

LS-207 Rev. June 1997

Notice of Employee's Injury or Death

LS-201 Rev Jan 1999

Notice of Final Payment or Suspension of Compensation Payments

LS-208 Rev. June 1998

Payment of Compensation Without Award

LS-206 Rev June 1997

Physician's Report on Impairment of Vision

LS-205 Rev Oct 1998

Pre-Hearing Statement

LS-18 Rev June 1997

Report of Earnings

LS-200 May 1998

Report of Injury Experience of Self-Insured Employer

LS-274 Rev. May 1998

Request for Examination and/or Treatment

LS-1 Rev May 1998

Request to Employee for Wage Earnings Information

LS-426 Rev. May 1998

Work Capacity Evaluation

Cardiovascular/Pulmonary Conditions

OWCP-5b Rev October 2001

Musculoskeletal Conditions

OWCP-5c Rev October 2001

Psychiatric/Psychological Conditions

OWCP-5a Rev October 2001

Occupational Safety and Health Administration (OSHA)

Log and Summary of Occupational Injuries and Illnesses

OSHA 200

Supplemental Record of Occupational Injuries and Illnesses

OSHA 101

Legal Forms

Submitted by scott on Mon, 01/05/2009 - 12:06

Interactive forms related to Workers' Compensation Cases

Legal Forms

General Science

NASA

One Pagers

Google Search