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Friday, April 19, 2024 -
WCC PDF Forms
| Form Name | Form 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 Conclusion | RB 105 |
| Request for consultative rating (02-2002) | |
| Request For Dismissal (General) | WCAB 43 |
| Request For Dismissal by Employee | WCAB-43 |
| Request For Dispute Resolution | RU 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-Insurer | DEU 201 |
| Request For Informal Rating Of Pre-Application Cases | DIA 400 |
| Request for Public Records (10-2006) | |
| Request For QME panel under Labor Code Section 4062.1 unrepresented | QME Form 105 |
| Request For QME Panel under Labor Code Section 4062.2 represented | QME 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 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 |
| Statement Of Decline Of Vocational Rehabilitation Services (1994 or later) | RU-107A |
| Stipulation and Award and/or Order | WCAB 5 |
| Stipulation And Order To Pay Lien Claimant | WC 904 |
| Stipulations With Request For Award | WCAB 3 |
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