California Workers’ Compensation Forms

What You Need to Know About California Workers’ Compensation Forms

The California Department of Industrial Relations website has a compiled list of all workers’ compensation forms. Here’s what you need to know about California’s workers’ compensation forms.

On California’s Department of Industrial Relations’ website, a worker can find all the necessary forms needed in a workers’ compensation case. The forms include audit, complaint, court, employer, medical forms, and much more. Below are some of the most frequently used forms.

Important and Frequently Used Forms for California Workers’ Compensation

California Labor Code §3700 requires every California employer to have workers’ compensation insurance. This is a type of liability insurance where the employer assumes complete liability for all worker injuries.

Workers’ Compensation Claim Form DWC 1

This form is for a worker who is injured or ill, either physically or mentally, because of their job, and may be entitled to workers’ compensation benefits. This includes injuries resulting from a workplace incident.
Notes for completing DWC 1:

Complete the “employee” section on the form. Keep one copy and give the rest to the employer.
Describe the injury in detail.
If mailing the form to the employer, use first-class or certified mail.
The employer must complete the “Employer” section on the form within one working day after the filed claim.

Audit Referral Form DWC-AU-906

This form may be used to file a complaint against the claim’s administrator. A claims administrator is charged with expediting the delivery of workers’ compensation benefits and services to injured workers.

Complaint Form Qualified Medical Evaluator (QME)

This form has the Investigations Unit of the DWC Medical Unit investigate complaints about physicians in the workers’ compensation system.

Application for Adjudication of Claim Form WCAB 1

This form is used in disputes of workers’ compensation cases. The form is typically used if there are disagreements with an insurer about medical treatment or the need to miss work. Disputes cannot be resolved unless this form is filed. Typically, this form needs to be filed within one year of the date of injury, within one year of the last day when the employer provided medical benefits, or within one year from the day any temporary disability benefits end.

Additional QME Panel Request Form QME 31.7

This form is used to receive a randomly generated list of three qualified medical evaluator (QME) physicians. The panel is issued when there is a question about whether or not the injury was work-related, or if there is a medical dispute that has not been resolved by the treating physician’s report.

The Medical Mileage Expense Form

The mileage form is used if an injured worker must travel to get treatment for their work injury. An injured worker receiving workers’ compensation is entitled to repayment of their travel costs. The millage rate is 56 cents per mile. Mileage considered reasonable is travel to the pharmacy, parking, bridge tolls, and public transportation.

The Notice to Employees—Injuries Caused by Work Form DWC 7

This form provides employees with information regarding workers’ compensation benefits and the Medical Provider Network (MPN) in California. The form is supposed to be provided to all new employees by the end of their first pay period.

The Physician’s Return-to-Work & Voucher Report DWC-AD 10133.36

This form is to fully inform the employer of the work capacities and activity restrictions from the injury are relevant to potential regular work, modified work, or alternative work. The information on the form is for voucher purposes.

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