WCC PDF Forms

Form Name	Form Number
Request For Reconsideration Of Summary Rating To The Administrative Director	DEU 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 Report	DEU 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
Stipulation and Award and/or Order	WCAB 5
Stipulation And Order To Pay Lien Claimant	WC 904
Stipulations With Request For Award	WCAB 3
Stipulations With Request For Award	WCAB 3
Stipulations With Request For Award (Death Case)	WCAB 4
Subpoena	SDT
Subpoena Duces Tecum - WCAB (06/94)	DWC 32
Subpoena Duces Tecum to Produce Records	CAsubpoenaform.pdf
Substitution Of Attorney	WCAB 36
Suspected Fraudulent Claim Referral Form	FD-1
Suspected Fraudulent Claim Report	SFC
TD Fact Sheet (Spanish)	TD Fact Sheet (SP)
Temporary Disability Fact Sheet	Fact Sheet 3a
The Basics About Medical Care for Injured Workers (2006)
The Injured Worker	THE INJURED WORKER
The Injured Worker (Spanish)	THE INJURED WORKER (SPANI
Utilization Review Complaint Form (01-2008)	DWC UR1
Venue Authorization	WC-105
What Every Worker Should Know	Fact Sheet #1
Workers' Compensation Claim Form (Rev 6/10)	DWC 1
Workers' Compensation Claim Form Instructions(Rev 6/10)	DWC 1
Workers' Compensation Claim Form with Instructions (05-2007)	I&A 1