Which California Workers' Comp Forms Do You Need?

Which California Workers' Comp Forms Do You Need?

There is no single state of California workers' compensation form that covers your whole claim. The DWC 1 claim form starts your case, and several other state forms come into play later, depending on how your claim unfolds.

A work injury often turns into a stack of unfamiliar paperwork. Some of it comes from your employer, some from the insurance company, and some from the Division of Workers' Compensation (DWC) itself. Each form has a specific job, a specific person who fills it out, and a specific moment when it shows up.

This guide walks through the forms most injured workers in California actually meet: the DWC 1 claim form, your employer's notices, the Request for Authorization for medical treatment, the QME panel request forms, the Application for Adjudication of Claim, the Declaration of Readiness to Proceed, the Supplemental Job Displacement Benefit (SJDB) voucher, and the RTWSP application. Every form name and number below comes from the Division of Workers' Compensation's own official forms page.

If you have not filed a claim yet, start with how to file a California workers' comp claim. This page picks up from there and explains the paperwork you may see at each later stage.

Is the DWC 1 the Only State of California Workers' Compensation Form?

No. The DWC 1 is the form most people mean when they search for "the" state of California workers' compensation form, but it only starts your claim. Several other state forms follow it.

The DWC 1 (Workers' Compensation Claim Form) is the document that puts your employer on notice that you are claiming a work injury. You fill out items 1 through 9: your name, address, the date, time, and place of the injury, the body parts affected, your Social Security number, and your signature. Your employer then completes items 10 through 19, covering the employer's information, the date it learned of the injury, and the insurance carrier's name and policy number.

Two deadlines matter here. Your employer must date the form and send copies to you and to the insurer or claims administrator within one working day of getting it from you. Separately, once you file the form, the employer or claims administrator must authorize up to $10,000 in treatment for your injury inside that same one-day window, even before anyone decides whether to accept the claim. The claims administrator then has 14 days to tell you whether your claim is accepted or needs more investigation. Signing the DWC 1 is not an admission that your employer caused the injury: that line is printed on the form itself.

For a closer look at that one-working-day rule, see the DWC 1 filing deadline guide. For the full filing process, from reporting the injury through getting the form back, see how to file a California workers' comp claim.

What Notices Must Your Employer Give You?

Your employer must post a notice explaining your rights, called the DWC 7, and must separately give new employees written information about workers' comp at the time they are hired.

Besides the claim form, two notices come from your employer rather than from you. The first is the workplace poster, DWC 7, "Notice to Employees, Injuries Caused by Work". It explains your right to medical care, temporary disability payments, the SJDB voucher, and death benefits in plain terms, and it restates the one-working-day claim form rule and the $10,000 treatment authorization rule in its own words.

The second is written information your employer must give new hires at the time they are hired, separate from the posted notice. This covers your rights in more detail, including how to name your own physician before an injury happens. You do not fill out either notice. They exist so you already know what to expect before you ever need a claim form.

Who Fills Out the Request for Authorization (RFA)?

Your treating physician fills out the Request for Authorization, not you. It is how your doctor formally asks the claims administrator to approve a specific treatment.

Once you are receiving care, your primary treating physician (PTP) uses the DWC Form RFA to request approval for a specific treatment, test, or piece of equipment. California Code of Regulations, title 8, section 9785.5 is titled "Request for Authorization Form, DWC Form RFA," and a related regulation spells out exactly how a request must be submitted:

Unless accepted by a claims administrator under section 9792.9.1(b), a request for authorization must be set forth on a "Request for Authorization (DWC Form RFA)" as contained in California Code of Regulations (CCR), title 8, section 9785.5, completed by a treating physician and as further outlined in this subdivision and in section 9785(h).

The requesting physician signs the form. The claims administrator's utilization review process then approves, modifies, or denies the request under Labor Code section 4610. If treatment is denied, you can ask for an Independent Medical Review (IMR) of that decision.

For a full walkthrough of how utilization review and IMR work, see Labor Code section 4610 and utilization review.

Which Form Do You Use to Request a QME Panel?

If you disagree with a medical opinion and do not have a lawyer, you or the claims administrator request a panel with QME Form 105. Represented workers often use a different path.

A qualified medical evaluator (QME) is an independent doctor who resolves medical disputes in your claim. If you are not represented by an attorney, you or the claims administrator request a panel using QME Form 105 (Labor Code section 4062.1).

If you are represented, the request works differently. QME Form 106, under Labor Code section 4062.2, only applies to injuries that happened before January 1, 2005. For injuries on or after that date, a represented worker's panel request goes through the DWC's online QME system instead of a paper form. Either way, if a panel needs to be replaced, or a second panel is needed for a different body part, separate forms (QME 31.5 and QME 31.7) handle those requests.

For more on how the QME process itself works, including what happens at the exam, see what a QME is and how it works.

What Is the Application for Adjudication of Claim?

This filing opens a case with the Workers' Compensation Appeals Board. You or your attorney file it when you need a judge to decide a dispute.

The Application for Adjudication of Claim (listed on the DWC's forms page as WCAB 1) is filed with the Workers' Compensation Appeals Board (WCAB), not with your employer or the insurer. Filing it chooses the county where your case will be heard, based on where you live, where the injury happened, or where your attorney's office is, per Labor Code section 5501.5.

The form asks what you disagree about: temporary disability, permanent disability, medical treatment or reimbursement, your pay rate, the SJDB voucher or return to work, or something else. If you are not represented, you sign it yourself. If you have an attorney or another representative, they sign it on your behalf.

See Labor Code section 5500 and when workers use this filing for more on why workers go this route.

What Is a Declaration of Readiness to Proceed?

Filing this document tells the Workers' Compensation Appeals Board that you are ready for a hearing, and it starts the clock on the other side's chance to object.

Once your case has an open file at the WCAB, either side can file a Declaration of Readiness to Proceed (DOR, DWC-CA form 10250.1) to request a hearing, such as a settlement conference, a status conference, or a priority conference. Whoever files it must state, under penalty of perjury, that they are actually ready to proceed and have made a genuine effort to resolve the dispute first.

Anyone who objects to the DOR must file and serve that objection within 10 days after it was served. A represented worker can ask for a priority conference under Labor Code section 5502(c) when the dispute involves whether you are an employee or whether the injury happened on the job. A lien claimant can only file this form after the main case is resolved, or after the worker chooses not to proceed, under Labor Code section 4903.6(c).

How Do You Claim the SJDB Voucher?

The claims administrator issues the SJDB voucher, but you sign it and choose how to spend the $6,000 it is worth, within a list of approved uses.

If your injury leaves you with a permanent disability and your employer does not offer regular, modified, or alternative work, you may qualify for the Supplemental Job Displacement Benefit voucher (DWC-AD form 10133.32). The claims administrator fills in the top section, including your claim number and the voucher's expiration date. You sign the bottom section and choose how to use the $6,000: retraining or education at an approved school, licensing or certification fees, up to $600 combined for job placement or counseling help, tools required by your training program, up to $1,000 for computer equipment, or up to $500 as a no-paperwork miscellaneous reimbursement. The claims administrator must reimburse documented expenses within 45 calendar days of receiving your paperwork. Disputes go on a separate form, DWC-AD 10133.55, to the DWC's Administrative Director.

Before the voucher is issued, your employer may instead send a Notice of Offer of Regular, Modified, or Alternative Work (DWC-AD form 10133.35). You have 30 calendar days to accept or reject that job offer. Rejecting it, or not responding, generally forfeits the voucher. If the offer is for modified or alternative work, four exceptions can still protect your voucher: you cannot physically do the job, the position will not last at least 12 months, the pay is below 85 percent of what you earned before the injury, or the commute is not reasonable. These exceptions do not apply if the offer is for your regular job. Your physician plays a part too: a short Physician's Return-to-Work and Voucher Report (DWC-AD form 10133.36) tells the claims administrator whether you can return to regular duty, which feeds into which of these two forms you receive.

For more on who qualifies for this benefit, see the SJDB voucher eligibility guide.

How Do You Apply for the Return-to-Work Supplement?

You apply for the RTWSP online, using your SJDB voucher as proof. It pays a separate, one-time $5,000 if you qualify.

The RTWSP is a different benefit from the SJDB voucher, run directly by the Department of Industrial Relations rather than your claims administrator. If your injury happened on or after January 1, 2013, and you received an SJDB voucher, you may qualify for an additional, one-time $5,000 payment.

You apply through the RTWSP online application (a kiosk is available at every DWC district office if you do not have internet access). You will need your case number, your workers' comp claim number, and the date your SJDB voucher was served on you. You must apply within one year of that service date. The DWC decides on complete applications within 60 days and pays within 25 days of that decision.

Forms and Deadlines at a Glance

These are the broader claim deadlines that connect to the forms above.

Reading about these forms is one thing. Getting one wrong, or missing a deadline tied to one, is what actually costs workers time and money. If you are unsure which form applies to your situation, or an insurance company is pressuring you to sign something you do not understand, call (661) 273-1780 or use the contact form. Yazdchi Law reviews each matter individually before deciding how it can help.

Eman Yazdchi represents injured workers across the Antelope Valley, the San Fernando Valley, and Greater Los Angeles, with appearances at the WCAB district offices in Van Nuys, Los Angeles, Long Beach, Pomona, San Bernardino, Riverside, and Oxnard.

Related Questions

Keep reading to understand the forms and deadlines that come before and after the ones on this page.

• How do I file a California workers' comp claim?
• How fast must my employer hand me the DWC 1?
• What is a QME in California workers' comp?
• Who qualifies for the SJDB voucher?
• When do workers file an Application for Adjudication?