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WCC PDF Forms

Form NameForm Number
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
Stipulation and Award and/or OrderWCAB 5
Stipulation And Order To Pay Lien ClaimantWC 904
Stipulations With Request For AwardWCAB 3
Stipulations With Request For AwardWCAB 3
Stipulations With Request For Award (Death Case)WCAB 4
SubpoenaSDT
Subpoena Duces Tecum - WCAB (06/94)DWC 32
Subpoena Duces Tecum to Produce RecordsCAsubpoenaform.pdf
Substitution Of AttorneyWCAB 36
Suspected Fraudulent Claim Referral FormFD-1
Suspected Fraudulent Claim ReportSFC
TD Fact Sheet (Spanish)TD Fact Sheet (SP)
Temporary Disability Fact SheetFact Sheet 3a
The Basics About Medical Care for Injured Workers (2006)
The Injured WorkerTHE INJURED WORKER
The Injured Worker (Spanish)THE INJURED WORKER (SPANI
Utilization Review Complaint Form (01-2008)DWC UR1
Venue AuthorizationWC-105
What Every Worker Should KnowFact 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

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