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WCC PDF Forms

Form NameForm Number
Report of suspected medical care provider fraud (03-2006)SMBFR 1115
Request for accomodations by persons with disabilities (Rev. 1/06)DWC Form 5
Request for authorization number form (05-2006)DWC AD 3
Request For ConclusionRB 105
Request for consultative rating (02-2002)
Request For Dismissal (General)WCAB 43
Request For Dismissal by EmployeeWCAB-43
Request For Dispute ResolutionRU 103
Request for dispute resolution before the administrative director injuries occurring on or after 01-01-2004 (08-18-2006)DWC-AD 10133.55
Request For Informal Rating By Insurance Carrier or Self-InsurerDEU 201
Request For Informal Rating Of Pre-Application CasesDIA 400
Request for Public Records (10-2006)
Request For QME panel under Labor Code Section 4062.1  unrepresentedQME Form 105
Request For QME Panel under Labor Code Section 4062.2  representedQME Form 106
Request for Qualified Medical Evaluator - Form with Instructions - SPANISH (05-2007)I&A2(sp)
Request for Qualified Medical Evaluator with Instructions (05-2007)I&A 2
Request for Reconsideration of Summary Rating by the Administrative Director - Form with Instructions - SPANISH (05-2007)I&A3(sp)
Request for Reconsideration of Summary Rating by the Administrative Director with Instructions (05-2007)I&A3
Request For Reconsideration Of Summary Rating To The Administrative DirectorDEU 103
Request for reimbursement of accommodation expenses - injuries on or after 07-01-2004 (08-18-2006)DWC-AD 10005
Request for summary rating determination (of AME's or QME 's report) (06-2005)DEU 101
Request for Summary Rating Determination of Primary Treating Physician's ReportDEU 102
Sample Initial Written Employee Notification Letter (06/2007)
Sample Initial Written Employee Notification Letter_Spanish (06/2007)
Settlement of prospective vocational rehabilitation services [LC 4646 (b)]RU 122
Statement of Decline of Vocational Rehabilitation Benefits (pre 1-1-1990)RB-107
Statement Of Decline Of Vocational Rehabilitation Services (1994 or later)RU-107A
Stipulation and Award and/or OrderWCAB 5
Stipulation And Order To Pay Lien ClaimantWC 904
Stipulations With Request For AwardWCAB 3

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