THE SHORT ANSWER
The DWC 1 is the one that matters most. Your employer must give it to you within one working day of learning about the injury, and if they do not, get it from the DWC and file it yourself. Filing it starts two clocks that protect you: up to $10,000 of treatment within one working day, and the 90-day presumption of compensability.
On this page
The one that matters most
Your employer must give it to you within one working day of learning about the injury. If they do not, get it from the DWCDWC Division of Workers’ Compensation, part of the Department of Industrial Relations. Administers the system. Information Services Center: 1-800-736-7401. and file it yourself.
| FORM | OFFICIAL NAME |
|---|---|
| DWC 1 | Workers’ compensation claim form |
Filing it starts two clocks that protect you. § 5402(c) — the employer must authorize up to $10,000 in medical treatment within one working day, and keep it authorized until liability is accepted or rejected. The duty covers the investigation period; it does not survive a rejection. § 5402(b) — if liability is not rejected within 90 days, the injury is presumed compensable, rebuttable only by evidence discovered after the 90 days.
Complete the employee section, sign it, date it, deliver it by certified mail or in person, and keep a copy showing the date. It is published in English, Spanish, Chinese, Korean, Tagalog, and Vietnamese.
Before you are injured
The law lets you name your own physician — but every requirement must be met before the injury. Health insurance covering non-occupational injuries; the physician is your primary care physician and has treated you; the physician has treated you before, keeps your medical records, and agrees in advance to be predesignated; and your employer is notified in writing before the injury occurs.
Every employer must give you this form at hire or by the end of your first pay period. Most workers never see it.
| FORM | OFFICIAL NAME |
|---|---|
| DWC 9783 | Notice of pre-designation of personal physician |
If you are not currently injured: file it today. It is ten minutes and it is worthless afterward.
Treatment
The RFARFA Request for Authorization. The form your doctor uses to request treatment. is what your doctor submits. It goes to utilization reviewUR Utilization Review. The process that approves, modifies, or denies each treatment request. A modification is a denial of what it left out., which approves, modifies, or denies it.
| FORM | OFFICIAL NAME |
|---|---|
| Form 9785.5 | Request for authorization for medical treatment (RFA) |
| DWC Form IMR | The application that appeals a utilization review denial — this is the one with the 10-day / 30-day clocks |
| DWC Form 9768.10 | A different form: MPN independent medical review, for a dispute with the second or third network opinion |
A modification is a denial of what it left out — and it starts the same 30-day IMRIMR Independent Medical Review. The appeal from a UR denial. 30 days (10 if the dispute is only over drugs on the MTUS Drug List). clock as an outright denial. The letter will say “approved.”
How to check a UR decision How IMR works
The IMR application appeals a UR denial. Thirty days. But check the UR decision’s timing first — a late UR decision goes to a judge rather than into IMR, which is a materially better forum.
Medical-legal evaluation
The panel process runs on short deadlines, and missing one can cost you the choice of specialty — frequently the most consequential decision in the medical development of the case.
| FORM | OFFICIAL NAME |
|---|---|
| QME 105 | Request for QME panel — unrepresented workers |
| QME 106 | Request for QME panel — represented workers, pre-2005 injuries only |
Litigation
The Application opens your case at the Appeals Board and gets you an ADJ numberADJ number Your case number at the Appeals Board.. One year.
8 CCR § 10744 — IF YOU ARE SERVED WITH A DORDOR Declaration of Readiness to Proceed. Forces the calendar. You have 10 calendar days to object, or objections to proceeding on its issues are waived., YOU HAVE 10 CALENDAR DAYS TO OBJECT
A party who does not object “shall be deemed to have waived any and all objections to proceeding on the issues specified in the declaration, absent extraordinary circumstances.”
| FORM | OFFICIAL NAME |
|---|---|
| WCAB 1 | Application for adjudication of claim |
| DWC-CA 10250.1 | Declaration of readiness to proceed (DOR) |
A DOR sets the mandatory settlement conferenceMSC Mandatory Settlement Conference. Where most cases end — and where discovery closes. 10 to 30 days out — and discovery closes at that conference.
Benefits
| FORM | OFFICIAL NAME |
|---|---|
| DWC-AD 10133.32 | Supplemental job displacement non-transferable voucher — injuries on or after 1/1/2013 |
Settlement documents
These are not numbered forms in the same way, and the title is what tells you which one you are holding.
COMPROMISE AND RELEASE
A lump sum that closes future medical treatment permanently.
STIPULATIONS WITH REQUEST FOR AWARD
An agreed percentage paid over time, with future medical left open and reopening available within five years of the date of injuryDate of injury For a cumulative or occupational disease claim, the law sets it as when you first suffered disability and knew or should have known it was work-related — not when the wear began. Almost every deadline runs off this..
Read the title before anything else.
Where to get any of them
All DWC forms are published free at dir.ca.gov/dwc/forms.html.
And every DWC district office has a free Information & Assistance officer who will help you complete them. The DWC Information Services Center is 1-800-736-7401.
Frequently asked questions
My employer never gave me a claim form.
They must give you a DWC 1 within one working day of learning about the injury. If they did not, get it free from the DWC and file it yourself — filing is what starts the $10,000 treatment obligation and the 90-day presumption.
Where do I get these forms?
Free at dir.ca.gov/dwc/forms.html, and every DWC district office has an Information & Assistance officer who will help you complete them. 1-800-736-7401.
Can I name my own doctor?
Only by predesignating on DWC 9783 before you are injured, and every requirement has to be met beforehand. It is worthless afterward.
The letter says my treatment was approved, but not all of it.
A modification is a denial of what it left out, and it starts the same 30-day IMR clock as an outright denial.
I was served with a Declaration of Readiness.
You have 10 calendar days to object, or objections to proceeding on the issues it lists are deemed waived absent extraordinary circumstances.
Which settlement document am I holding?
Read the title. A Compromise and ReleaseC&R — Compromise and Release A lump sum that closes future medical treatment permanently. closes future medical permanently; Stipulations with Request for AwardStips — Stipulations with Request for Award An agreed percentage paid over time, with future medical left open, and reopening available within five years of the date of injury. These are not two prices for the same thing. leaves it open with five years to reopen from the date of injury.
Sources
Labor Code § 4062.1§ 4062.2§ 4600(d)§ 4610.5§§ 4616.3–4616.4§ 5401§ 5402(b), (c)§ 5405§ 5502(d)(3)8 CCR § 9768.10§ 9792.10.2§ 10744DWC forms library at dir.ca.gov/dwc/forms.htmlDWC Information Services Center, 1-800-736-7401.
General information about California law, not legal advice about your case.
Reviewed by Jamey Teitell, Partner & Trial Attorney · Last reviewed
Law Offices of Solov & Teitell, APC · (213) 380-9310
Printed from https://www.solovteitell.com/resources/forms/ · Last reviewed