Legal Solutions™ Plus Workers’ Compensation Forms

Forms change rapidly, this list represents a sample.

• WC–004 Addendum to Application and/or Answer
• WCAB–001 Address Record Change
• WCAB–003 Affidavit of Defendant Re: Resolution of Liens
• WCAB–10 Answer
• WCAB–2 Answer (Injuries Occurring On/After January 1, 1990)
• DWC–400 Application for Access to WCAB Index Cards and Computer by DWC Staff
• DIA–1 Application for Adjudication of Claim
• DIA–2 Application for Adjudication of Claim (Death Case)
• WCAB–1A Application for Adjudication of Claim (Death Case) [Injuries Occurring On/After January 1, 1990)
• WCAB–1 Application for Adjudication of Claim (Injuries Occurring On/After January 1, 1990)
• IMC–10 Application for Appointment as Qualified Medical Evaluator
• LS–266 Application for Continuation of Death Benefit for Student
• IMC–16 Application for QME Competency Examination (September 21, 1996)
• DEU–105 Apportionment
• WCAB–32 Arbitration Submittal Form
• WCAB–33 Arbitration Submittal Orders
• WCAB–002 Arbitrator Application
• WCATTACH Attachment Page
• LS–204 Attending Physician's Supplementary Report
• DWC–906 Audit Referral Form
• IMC–76 Billing and Statement of Charges for Medical—Legal Reports
• RU–101 Case Initiation Document
• LS–265 Certification of Funeral Expenses
• DWC–1194 Choosing Medical Care for Work-Related Injuries and Illnesses
• 982A151 Civil Subpoena (Duces Tecum) for Personal Appearance and Production of Documents and Things at Trial or Hearing and Declaration
• 982A15 Civil Subpoena for Personal Appearance at Trial or Hearing
• LS–262 Claim for Death Benefits
• DIA–15 Compromise and Release
• DIA–16 Compromise and Release (Dependency Claim)
• DIA–17 Compromise and Release (Third Party)
• DIA–11 Consultative Evaluation Request (Fresno)
• WC–104 Data Entry Sheet
• LS–600 Declaration of Custodian of Records
• DIA–9 Declaration of Readiness to Proceed
• WC–006 Declaration Pursuant to Labor Code Section 4906(g)
• IMC–5 Denial of Time Extension
• DWC–500P Denial of Vocational Rehabilitation Benefits
• 982A152 Deposition Subpoena for Production of Business Records
• RB–91 Description of Employee's Job Duties
• RU–91 Description of Employee's Job Duties
• WC–4 Disclaimer
• DWC2 Disclosure Statement Withdrawal
• WC–1 Doctor's First Report of Occupational Injury or Illness
• RU–107A Employee Statement of Declination of Vocational Rehabilitation Services (Injuries Occurring On/After 1/1/94)
• RU–107 Employee Statement of Declination of Vocational Rehabilitation Services (Pre 1/1/90)
• LS–203 Employee's Claim for Compensation
• DWC–1 Employee's Claim for Workers' Compensation Benefits
• DEU–100 Employee's Permanent Disability Questionnaire
• DEU10095 Employee's Permanent Disability Questionnaire (for Injuries on or After 1/1/91)
• DIA–200 Employee's Request for Informal Permanent Disability Rating
• LS–202 Employer's First Report of Injury or Occupational Illness
• WC–5020 Employer's Report of Occupational Injury or Illness [Generic Version]
• II–5020 Employer's Report of Occupational Injury or Illness [Industrial Indemnity Form]
• LS–210 Employer's Supplementary Report of Accident or Occupational Illness
• WCAB–106 Exhibit & Witness Cover Sheet
• LS–002 Expedited Settlement Conference Information Sheet
• DWC3 Fee Disclosure Statement
• WC–6 File Request Slip
• WC–HCO1 HCO Enrollment Form
• WC–1500 Health Insurance Claim Form
• IM12202 How to Request a Qualified Medical Evaluator
• WC–IG Information Guidelines for Submission of Settlement Documents
• WC–7A Information Request Form
• WC–7B Information Response Form
• RU–120 Initial Evaluation Summary
• IM12203A Injured Worker Information
• DWC–500N Intent to Withhold Vocational Rehabilitation Maintenance Allowance
• IM12203B Letter to Injured Worker Re QME Physicians
• WC–2 Lien Claim Return Form
• WCAB–105 Minutes of Hearing/Appearance Sheet Order and Decision on Request for Continuance or Off Calendar
• WCAB055 Minutes of Hearing/Order/Order and Decision on Request for Continuance/Order Taking Off Calendar/Notice of Hearing
• DWC–6 Notice and Request for Allowance of Lien
• DWC–500F Notice of Change in Rate or Payment Schedule
• LS–207 Notice of Controversion of Right to Compensation
• DWC–500D Notice of Delay in Determining Liability for Workers' Compensation Benefits
• DWC–500E Notice of Denial of Claim for Workers' Compensation Benefits
• DWC–500C Notice of Denial of Permanent Disability Benefits
• DWC–500H Notice of Denial of Workers' Compensation Dependency Benefits
• DIA–37 Notice of Dismissal of Attorney
• DIA–510 Notice of Employee Death
• LS–0201 Notice of Employee's Injury or Death
• LS–208 Notice of Final Payment or Suspension of Compensation Payments
• WCAB–12 Notice of Hearing
• WC–001 Notice of Hearing to Lien Claimants
• DIA–29 Notice of Intention
• DIA–29A Notice of Intention to Disallow Lien and Order
• DWC–500O Notice of Interruption or Deferral of Vocational Rehabilitation Services
• IMC–7 Notice of Late QME Report
• RU–94 Notice of Offer of Modified or Alternative Work
• DWC–500J Notice of Potential Eligibility and Delay of Vocational Rehabilitation
• DWC–500L Notice of Potential Eligibility for Vocational Rehabilitation
• IMC12210 Notice of QME Unavailability/Availability
• WC–18 Notice of Taking Deposition
• RU–105 Notice of Termination of Vocational Rehabilitation Services
• DWC–500B Notice Regarding Permanent Disability Benefits
• DWC–500A Notice Regarding Temporary Disability Benefits
• DWC–500I Notice Regarding Vocational Rehabilitation
• DWC–500M Notice Regarding Vocational Rehabilitation Maintenance Allowance
• WC–002 Notice Regarding Workers' Compensation Claim (Claim Filed Prior to 1/1/94; Benefits Furnished; No Activity for 180 Days)
• WC–003 Notice Regarding Workers' Compensation Claim (Claim Filed Prior to 1/1/94; Claim Denied; No Activity for 180 Days)
• DWC–500G Notice Regarding Workers' Compensation Dependency Benefits
• WC–5 On-Line Correction Request
• WC–901 Order Allowing Attorney's Fees (Rehabilitation Proceeding)
• WC–902 Order Allowing Payment of Lien (On Condition)
• WC–1050 Order and Decision on Request for Continuance or Off Calendar
• DIA–65F Order Approving Compromise& Release
• LS–65 Order Approving Compromise& Release (Template Format)
• WC–65D Order Approving Compromise and Release
• DIA–65D Order Approving Compromise and Release
• DIA–65 Order Approving Compromise and Release
• DIA–65P Order Approving Compromise and Release
• DIA–65E Order Approving Compromise and Release (Release of Applicant's Defendants' Rights to Death Benefits—Rogers V. WCAB)
• DIA–65C Order Approving Compromise and Release (Release of Applicant's Rights to Death Benefits)
• WCAB–5 Order Approving Compromise and Release (Right to Rehabilitation is Not Abrogated by This Order)
• DIA–65A Order Approving Compromise and Release (Rodgers vs. WCAB)
• WCAB–67 Order Approving Compromise and Release (Third Party Settlement)
• DIA–65B Order Approving Compromise and Release (Thomas vs. Sports Chalet, Inc.)
• WCAB–52 Order Dismissing Party Defendant
• WC–905 Order Granting Payment of Lien Claim
• WCAB–53 Order Joining Party Defendant
• WCAB–51 Order of Dismissal
• WCAB–59 Order to Report to Independent Medical Examiner
• LS–206 Payment of Compensation Without Award
• DWC500BF Permanent Disability Fact Sheet
• WCAB–8 Petition for Appointment of Guardian Ad Litem and Trustee
• WC–100 Petition for Benefits/Penalty
• DWC–280 Petition for Change of Primary Treating Physician
• DIA–280 Petition for Change of Primary Treating Physician
• WCAB–49 Petition for Commutation of Future Payments
• WC–900 Petition for Order Allowing Attorney's Fees
• WCAB–31 Petition for Order Allowing Pre- Application Attorney Fee and Order
• WCAB–41 Petition for Permanent Disability Rating
• WCAB–30 Petition for Pre-Application Discovery Order
• WCAB–45 Petition for Reconsideration
• WCAB–42 Petition to Reopen
• WCAB–46 Petition to Terminate Liability for Temporary Disability Indemnity
• PP–300 Pleading Paper
• LS–304 Pleading Paper—1st Page— Workers' Comp Heading
• PP–301 Pleading Paper Attachment
• WCAB–30A Pre-Application Discovery Order
• LS–18 Pre-Hearing Statement