Workers' comp forms and where to get them
The forms that move a California workers' comp claim are all published by the Division of Workers' Compensation and are free. The worker's form is the DWC-1 claim form, which the employer must provide within one working day of learning of an injury. The employer's are the Form 5020 report to its insurer within five days, the DWC-7 poster and the time-of-hire notice. The medical forms are the Request for Authorization and the QME panel requests, Forms 105 and 106. Disputes and settlements use the appeals board's Application for Adjudication and the Stipulations and Compromise and Release forms.
The forms, in the order a claim meets them
The table lists each form, who files it and when, and the section that requires it. Links go to the official DWC copy or, where the form is maintained by the appeals board, to the DWC forms index that hosts it.
| Form | Who files it and when | Authority |
|---|---|---|
| DWC-1 — Workers' Compensation Claim Form and Notice of Potential Eligibility | Employee completes; employer provides within one working day of notice of injury and returns a dated copy. | Labor Code §5401 |
| Form 5020 — Employer's Report of Occupational Injury or Illness | Employer files with its insurer within five days of knowledge of an injury causing lost time beyond the shift or treatment beyond first aid. | Labor Code §6409.1; 8 CCR §14001 |
| DWC-7 — Notice to Employees: Injuries Caused by Work (poster) | Employer posts where employees gather; names the insurer and claims administrator. | Labor Code §3550; 8 CCR §9881 |
| Time of Hire Notice (pamphlet) with personal physician predesignation form | Employer gives to every new hire at the time of hire or by the end of the first pay period. | Labor Code §3551; 8 CCR §9880 |
| DWC Form RFA — Request for Authorization for Medical Treatment | Treating physician sends to the claims administrator to start utilization review. | Labor Code §4610 |
| QME Form 105 — Request for Qualified Medical Evaluator panel (unrepresented) | Injured worker without an attorney, or the claims administrator, requests a three-doctor panel. | Labor Code §4062.1 |
| QME Form 106 — Request for Qualified Medical Evaluator panel (represented) | Either party requests a panel when the worker has an attorney and no AME is agreed. | Labor Code §4062.2 |
| Application for Adjudication of Claim | Opens a case at a WCAB district office when the worker and claims administrator disagree; must be filed within the Labor Code §5405 period. | Labor Code §5405 |
| Declaration of Readiness to Proceed | Asks the WCAB to set a hearing once a dispute is ready. | WCAB Rules |
| Stipulations with Request for Award; Compromise and Release | The two settlement forms, each submitted to a judge for approval. | Labor Code §4906; §5410 |
Notes on the ones that matter most
DWC-1. One document, in English and Spanish, that is both the claim form and the Notice of Potential Eligibility. The employee completes the top section and keeps a copy; the employer completes the bottom, dates it, returns a dated copy to the employee and sends one to the claims administrator (Labor Code §5401; 8 CCR §10139). The date the employer received it is the filing date that starts the 90-day decision period and the one-working-day treatment authorization. The how to file page walks through it line by line.
Form 5020. The employer's report to its insurer of every injury causing lost time beyond the shift or treatment beyond first aid, due within five days of the employer's knowledge (Labor Code §6409.1(a); 8 CCR §14001). It is the first document the adjuster reads and the one that most often sets the tone of the investigation; a complete description of how the injury happened, taken the same day, serves the employer better than a cursory one.
DWC-7 and the time-of-hire notice. The poster and the pamphlet are the employer's standing notices (Labor Code §3550, §3551; 8 CCR §9881, §9880). The insurer supplies both. The pamphlet includes the personal-physician predesignation form, which is the only way an employee can arrange to be treated by their own doctor from the first visit.
Request for Authorization. The treating physician's one-page request to the claims administrator for a specific treatment, which starts the utilization review clock (Labor Code §4610). Workers do not file it, but the denial that may follow comes with the independent medical review application, which the worker must return within 30 days.
QME Forms 105 and 106. Form 105 is the unrepresented worker's request to the DWC Medical Unit for a three-doctor panel (Labor Code §4062.1); Form 106 is the represented version with the strike process (Labor Code §4062.2). If the claims administrator sends a worker Form 105, the worker has 10 days to submit it or the administrator may. The QME page explains the choices on the form.
Application for Adjudication of Claim. The form that opens a case at a Workers' Compensation Appeals Board district office when there is a dispute. It must be filed within the one-year period in Labor Code §5405 (tolled while a filed claim form is pending) and is the step that gives the worker a judge. An Information and Assistance officer will explain to an unrepresented worker how to complete and file it.
Stipulations with Request for Award and Compromise and Release. The two settlement forms, each of which a judge must review and approve before it takes effect (Labor Code §4906 governs the attorney fee shown on it). The settlements page explains what each one gives up.
Questions people ask
Do I have to use the official form?
For the DWC-1, the Form 5020, the QME requests and the appeals board filings, yes; the regulations prescribe them, and a claims administrator or the Medical Unit can reject a substitute. Letters and emails are fine for reporting an injury to a supervisor or objecting to a medical report, but keep a copy and a date.
Where do I file the DWC-1?
With your employer, in person or by mail, not with the state. The claim is filed when the employer receives it (Labor Code §5401(c)). The employer completes its section, gives you a dated copy and forwards it to its claims administrator.
Is there a fee for any of these forms?
No. DWC and WCAB forms are free to download and free to file. An attorney may not charge you for completing them except as part of a fee a judge later approves.
Can forms be filed electronically?
Attorneys and claims administrators file with the appeals board through its electronic adjudication system; unrepresented workers can file paper forms at a district office or by mail. The DWC-1 is exchanged between worker and employer on paper or, if the employer offers it, electronically.
Sources
- DWC forms index, DIR / DWC, current. Manifest S66.
- DWC Form 1 (claim form) - direct PDF, DIR / DWC, current. Manifest S68.
- Workers' Compensation Claim Form (DWC 1) & Notice of Potential Eligibility (English/Spanish), DIR / DWC, current approved form. Manifest S34.
- DWC Form 7: Notice to Employees - Injuries Caused by Work (poster), DIR / DWC, effective 2025-01-01. Manifest S67.
- Time of Hire Notice, DIR / DWC, current (AD-approved). Manifest S02.
- DWC Form RFA: Request for Authorization for Medical Treatment, DIR / DWC, current. Manifest S69.
- QME Form 105: Request for QME panel (unrepresented, LC 4062.1), DIR / DWC, current. Manifest S70.
- QME Form 106: Request for QME panel (represented, LC 4062.2), DIR / DWC, current. Manifest S71.
- 8 CCR 10139 Workers' Compensation Claim Form (DWC 1) and Notice of Potential Eligibility, DIR (regulation text), current. Manifest S85.
- 8 CCR 14001 Employer (Form 5020 five-day filing), DIR (regulation text), current. Manifest S81.
- 8 CCR 9881 Posting of Notice to Employees, DIR (regulation text), current. Manifest S83.
- 8 CCR 9880 Written Notice to New Employees, DIR (regulation text), current. Manifest S84.
- Labor Code 5401: Claim form within one working day; $10,000 treatment, California Legislature via california.public.law (cites leginfo), current. Manifest S123.
- Labor Code 6409.1: Employer report of injury (Form 5020), California Legislature via california.public.law (cites leginfo), current. Manifest S132.
- Labor Code 3550: Posting of notice, California Legislature via california.public.law (cites leginfo), current. Manifest S99.
- Labor Code 3551: Time-of-hire written notice, California Legislature via california.public.law (cites leginfo), current. Manifest S98.
- Labor Code 4610: Utilization review, California Legislature via california.public.law (cites leginfo), current. Manifest S113.
- Labor Code 4062.1: QME panel, unrepresented, California Legislature via california.public.law (cites leginfo), current. Manifest S119.
- Labor Code 4062.2: QME panel, represented, California Legislature via california.public.law (cites leginfo), current. Manifest S120.
- Labor Code 5405: One-year statute of limitations, California Legislature via california.public.law (cites leginfo), current. Manifest S125.
- Labor Code 4906: Attorney fee approval, California Legislature via california.public.law (cites leginfo), current. Manifest S136.
Richard Vaughn spent 35 years in commercial property and casualty insurance, most of it in workers' compensation: running a self-insured group, auditing premiums, and implementing claims systems for carriers and third-party administrators. He is not an attorney. dickvaughn.com