The Forms

Every form you will encounter, what it does, and — more importantly — what clock it starts.

The one that matters most

Your employer must give it to you within one working day of learning about the injury (§ 5401). If they do not, get it from the DWC and file it yourself.

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

§ 4600(d) 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 agrees in advance and agrees to retain your records · and your employer is notified in writing before the injury occurs.

Employers with an MPN must give you this form at hire or before the end of your first pay period. Most workers never see it.

If you are not currently injured: file it today. It is ten minutes and it is worthless afterward. Requirements.

Treatment

The RFA is what your doctor submits. It goes to utilization review, which approves, modifies, or denies it.

A modification is a denial of what it left out — and it starts the same 30-day IMR clock as an outright denial. The letter will say "approved." More.

The IMR application appeals a UR denial. Thirty days. But check the UR decision for procedural defects first — a defective UR decision goes to a judge rather than into IMR, which is a materially better forum. How to check.

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. How the QME process works.

Litigation

The Application opens your case at the Appeals Board and gets you an ADJ number. One year (§ 5405).

The DOR forces the calendar — and if you are served with one, you have 10 calendar days to object. Under 8 CCR § 10744, 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."

A DOR sets the mandatory settlement conference 10 to 30 days out — and discovery closes at that conference under § 5502(d)(3). Why that matters most.

Benefits

How the voucher works.

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 injury.

Read the title before anything else. The difference.

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. Where the offices are.