California Forms

 9 State Forms found

name number revision print or send online


Form 5021 (Rev. 5) 10/2015


FORM 5020 (Rev7) June 2002

Workers’ Compensation Claim Form (DWC 1) & Notice of Potential Eligibility - Formulario de Reclamo de Compensación de Trabajadores (DWC 1) y Notificación de Posible Elegibilidad

DWC 1 Rev. 1/1/2016


DWC-CA form 10214 (e) REV. 11/2008

Notice to Employees - Injuries Caused By Work

DWC 7 1/1/2016

Basic Facts on Workers' Compensation for Injured Workers

No Form Number July 2010


No Form Number Julio 2014

Time of Hire Pamphlet

No Form Number July 2014


DWC-AD form 10133.35 (SJDB) EFF: 1/1/14
Disclaimer: These forms may not be the most recent version. California may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on this site. Please check official sources.

California Contacts

name title/position phone/email/web

Division of Workers Compensation

N/A 800-736-7401

Department of Insurance

N/A 510-622-2660

Department of Industrial Relations

N/A 213-897-5267

Michael Wimberly

Executive Officer 916-274-5751

Jamie Meyers

Supervisor (Headquarters) 916-574-0300

Lyn Asio

Supervisor (Northern California Audit Team) 916-574-0300

Marilee Robinson

Supervisor (Southern California Audit Team) 916-574-0300

Art Carter

Chairperson, Labor Member 916-274-5751
More State Contacts

California Insurance Requirements

State Fund and Self-Insurance Information

State Fund?
Injured worker claim form?
Basis of the state WC medical fee schedule
Basic fee schedule reimbursement provisions
General medical benefit provisions
Report an injury/illness claim
General medical benefit limitations
Private Insurance Carriers?
Self-insurance - Individual Employers?
State has a Medical Fee Schedule?
Self-insurance - Groups of Employers/Pools?

Insurance Requirements for Workers' Compensation

Injured worker claim form for death benefits?
Insurance Compulsory or Elective?
Form for injured worker to revoke prior rejection workers' compensation?
Penalties/fines/assessments for not carrying workers' compensation insurance?
Class of penalty/offense/crime is applicable for not having insurance
Waivers Permitted?
Form for injured worker to reject terms of workers' compensation?
Numerical Exemptions?
Workers' compensation medical E-Bill Requirements?
Exemptions for Private Employers?
Exemptions for Public Entities?
Special Coverage Provisions?
Injured worker assistance on the Web or a State Hotline Ombudsman?

Coverage for Agricultural and Domestic Workers

Required for Agricultural workers?
Home page on State Web site for the Injured Worker?
Exceptions for Agricultural Employees?
State FAQ Sheet for Injured Worker?
Required for Domestic workers?
Coverage for Domestic Workers voluntary?
State explanation of claim process available for Injured Worker?
Can Domestic Workers be specifically excluded?
Coverage for Agric/Domestic workers the same as for other employees?

Misc. State Insurance Information

Drug Free Workplace and/or Testing Policies?
Special provisions for providing workers' comp to volunteer firefighters?
Special provisions for death benefits for volunteer firefighters?

Coverage for Minors

Minors covered by workers' compensation insurance?
More State Insurance Requirements

California Compensation Laws

Waiting Periods

Waiting period for indemnity (loss wages)
Retroactive Period

Minimum and Maximum Indemnity Benefits

Weekly PPD Min/Max Benefits
Weekly PTD Min/Max Benefits
Weekly TTD Min/Max Benefits
Weekly TPD Min/Max Benefits

Death Benefits

Weekly Min/Max Death Benefits
Time Limits for Death Benefits
Compensation limits for surviving spouse and child(ren)
Maximum Burial Allowances for a death claim
Effective Date for these Benefits

Maximum Compensation Adjustment Dates and Percentages for Indemnity

Adjustment date for the maximum compensation
Min/Max percentage of SAMW or SAWW
Percentage of wages used to calculate the benefit rate
Offsets for Temporary Disability?

Method of Payment for Disability Awards

Scheduled awards paid in addition to TTD benefits?
Scheduled awards paid upon termination of TTD benefits?
Scheduled awards reduced because of receipt of TTD benefits?

Benefits for Permanent Disfigurement

Nature of Disfigurement Policy
Compensation received
Maximum Period

Misc. State Compensation Information

Method of payment of compensation
Mileage reimbursement rate for injured workers

Compensation for Minors

Future earning capacity of minor worker considered?
Special benefit provisions for minor workers?

Second/Special Injury Fund

Second/Special Injury Fund?
Portion payable by the employer?
Portion payable by the fund?
Source of the Fund
More State Compensation Laws

California Medical Guidelines

Physician Selection

Employee make Initial choice for a Physician?
Employee required to select a Physician from a list prepared by a State Agency?
Employee required to select a Physician from a list maintained by the Employer?
Employer select the Physician (direct where the Employee must go)?
State Agency change the Employer's Initial Physician Selection?
Employee have free choice after a specified period of time?

Misc. Medical Policies

Full medical benefits provided under state workers' compensation system?
Permissible to settle Medical Benefits under workers' compensation system?
Offset provisions under the State's workers' compensation system?
Medicare Offsets?
Artificial appliances covered?
Prayer and/or spiritual treatment covered?
More State Medical Guidelines

California Admin/Reporting

First Report of Injury Form Information

State's First Report of Injury form
Number of the form (if applicable)
Revision date of the First Report of Injury form
Which State Agency administers workers' comp claims?

First Report Submission Requirements and Preferences

State's Preferred Method for receiving the First Report
State accepts claims via EDI?
State accepts claims via Email?
State accepts claims via FAX?
State accepts claims via Online?
State accepts claims via US Mail?

Reporting Requirements

Types of Injuries/Accidents the Employer is required to report
Injuries/Illnesses not covered?
Date the State requires the First Report to be submitted
Time Requirement for the Injured Worker to File a Claim
Employer Required to Keep Records of Claims?


Monetary Penalties for Failure to Report?
Imprisonment Penalties for Failure to Report?

Vocational Rehabilitation and Return to Work Policies

Rehab Services are Provided by the State
Employer/Carrier Responsibilities for Voc Rehab
Employee's responsibilities regarding Voc Rehab
Penalties to the Employee for non-compliance
Employee's benefits during Voc Rehab
Services are provided by the State WC Rehab Unit
State's Codes/Regulations for Voc Rehab
Funding source for the rehabilitation of disabled workers
Maintenance Allowance Benefits provided during rehabilitation of Disabled Workers?

Fraud Provisions

Does the State have a Fraud Bureau?
Claim Fraud defined as a specific crime?
Underwriting Fraud a specific crime
Insurer Fraud a specific crime?
Fraud Plan required?
SIU required?
Annual Fraud Reports required?
Fraud Warning required?
Fraud provisions for Insurer-to-Insurer fraud?
Notify the Licensing Board?

Immunity Provisions

Specific Immunity for Insurer to Insurer?
Specific Immunity for reporting to Law Enforcement?
Specific Immunity for reporting to the Fraud Bureau?
Specific Immunity for reporting to the NAIC?
Specific Immunity for reporting to the NICB?

Subrogation Statutes and Provisions

Carrier sue the Third Party directly?
UM/UIM Recovery?
State's Subrogation Statutes

Medical Malpractice Statutes and Provisions

Medical Malpractice as a Third Party?
Legal Malpractice as a Third Party?
Recovery Limits
Employer Negligence?
Future Credit?
Personal Injury Statute of Limitations

Reporting Requirements and Information for Occupational Diseases

Occupational Diseases are covered
Time limit for filing a claim for Occupational Disease
Medical Care Provisions for Occupational Disease claims
Compensation Provisions for Occupational Diseases
Claims settled or resolved

Administration and Appeals Provisions

Time limit for modifications of award?
Attorney Fees determined?
Method for paying Attorney's Fees
Administrative agency that has purview over appeals provisions
Time requirement to file an appeal
Court(s) for Appeals
Process and procedure for filing an appeal
Appeal process by way of a Jury Trial?
More State Administration
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