California Department of Industrial Relations Forms
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DLSE WCA Form 1 "Initial Report or Claim" - California
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39 votes
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DLSE WCA Form 1 "Initial Report or Claim" - California (Chinese)
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55 votes
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DLSE WCA Form 1 "Initial Report or Claim" - California
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DLSE WCA Form 1 "Initial Report or Claim" - California (Korean)
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Form I&A4 "Information & Assistance Unit Guide - How to File an Application for Adjudication of Claim" - California
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17 votes
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5 MB
18 pages
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Form I&A6 "Information & Assistance Unit Guide - How to Request an Expedited Hearing" - California
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23 votes
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4 MB
12 pages
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Form I&A5 "Information & Assistance Unit Guide - How to File a Declaration of Readiness to Proceed" - California
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29 votes
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3 MB
13 pages
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Form EPA-1 "Equal Pay Act Complaint" - California
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32 votes
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258 KB
3 pages
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Form A-5 "Corporate Resolution Authorizing Application to the Director of Industrial Relations, State of California for a Certificate of Consent to Self-insure Workers' Compensation Liabilities" - California
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1 MB
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Form A-6 "Agreement and Undertaking for Security Deposit" - California
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53 votes
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Form A-4 "Guaranty of Workers' Compensation Liabilities" - California
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41 votes
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Form S-3 "Corporate Resolution Authorizing Application to the Director of Industrial Relations, State of California for a Certificate of Consent to Self-insure Workers' Compensation Liabilities" - California
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71 votes
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Form S-6 "Agreement and Undertaking for Security Deposit" - California
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42 votes
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Form A-1 "Application for Certificate of Consent to Self-insure as a Private Employer Self-insurer" - California
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46 votes
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Form A-2 "Application for Certificate of Consent to Self-insure as a Public Agency Employer Self-insurer" - California
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68 votes
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3 MB
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Form S-1 "Group Master Application for Certificate of Consent to Self-insure as a Group Self-insurer" - California
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Form S-4 "Indemnity Agreement and Power of Attorney" - California
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Form S-5 "Agreement of Assumption and Guarantee of Workers' Compensation Liabilities for Group and Affiliate Members" - California
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Form I&A1 "Information & Assistance Unit Guide - How to File a Workers' Compensation Claim Form" - California
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Form RCI1 "Retaliation Complaint" - California
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46 votes
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Formulario RCI1 "Queja Sobre Represalias" - California (Spanish)
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64 votes
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Formulario DLSE-PW1 "Reclamo De Trabajadores De Obras Publicas" - California (Spanish)
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47 votes
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211 KB
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Form DLSE-PW1 "Public Works - Worker Complaint" - California
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29 votes
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350 KB
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DLSE Form 1 "Initial Report or Claim" - California (Tagalog)
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31 votes
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DLSE Form 1 "Initial Report or Claim" - California
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Form DLSE8 "Payday Notice" - California
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20 votes
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Form P-1 "Self-insurer's Profile and Financial Summary Report" - California
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19 votes
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411 KB
10 pages
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Form J-1 "Joint Powers Authority (Jpa) Self-insurer's Profile and Financial Summary Report" - California
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26 votes
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423 KB
10 pages
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Form I&A19 "Information & Assistance Unit Guide - How to File a Petition Appealing Administrative Director's Independent Medical Review Determination" - California
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33 votes
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Form I&A12 "Information & Assistance Unit Guide - How to File a Petition for Reconsideration" - California
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8 votes
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Form DAS4A "Division of Apprenticeship Standards Complaint Form" - California
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34 votes
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166 KB
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Form A-3A "Private / Public Interim Application" - California
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56 votes
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Form A-3B "Application for Permanent Certificate of Consent to Self-insure for Interim Self-insurer" - California
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54 votes
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Form S-2B "Application for Affiliate Certificate of Consent to Self-insure as a Member of a Group Self-insurer" - California
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70 votes
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Form S-2A "Group Affiliate Member Interim Application" - California
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WCAB Form 24 "Pre-trial Conference Statement" - California
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30 votes
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4 MB
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Form 33 "Safety and Health Program Assessment Worksheet" - California
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80 votes
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52 KB
11 pages
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DWC/WCAB Form 37 "Notice of Dismissal of Attorney" - California
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25 votes
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Form DWC-AU-906 "Audit Complaint Form" - California
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44 votes
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87 KB
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Form OSHAB-316 "Subpoena Re Deposition" - California
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22 votes
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297 KB
4 pages
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![DLSE WCA Form 1 "Initial Report or Claim" - California](https://data.templateroller.com/pdf_docs_html/2260/22601/2260161/dlse-wca-form-1-initial-report-or-claim-california.png "DLSE WCA Form 1 "Initial Report or Claim" - California")
![DLSE WCA Form 1 "Initial Report or Claim" - California (Chinese)](https://data.templateroller.com/pdf_docs_html/2188/21887/2188784/dlse-wca-form-1-initial-report-or-claim-california-chinese.png "DLSE WCA Form 1 "Initial Report or Claim" - California (Chinese)")
![DLSE WCA Form 1 "Initial Report or Claim" - California](https://data.templateroller.com/pdf_docs_html/2100/21006/2100659/dlse-wca-form-1-initial-report-or-claim-california.png "DLSE WCA Form 1 "Initial Report or Claim" - California")
![DLSE WCA Form 1 "Initial Report or Claim" - California (Korean)](https://data.templateroller.com/pdf_docs_html/2188/21887/2188785/dlse-wca-form-1-initial-report-or-claim-california-korean.png "DLSE WCA Form 1 "Initial Report or Claim" - California (Korean)")
![Form I&A4 "Information & Assistance Unit Guide - How to File an Application for Adjudication of Claim" - California](https://data.templateroller.com/pdf_docs_html/2325/23254/2325497/form-i-a4-information-assistance-unit-guide-how-to-file-an-application-for-adjudication-of-claim-california.png "Form I&A4 "Information & Assistance Unit Guide - How to File an Application for Adjudication of Claim" - California")
![Form I&A6 "Information & Assistance Unit Guide - How to Request an Expedited Hearing" - California](https://data.templateroller.com/pdf_docs_html/2325/23254/2325493/form-i-a6-information-assistance-unit-guide-how-to-request-an-expedited-hearing-california.png "Form I&A6 "Information & Assistance Unit Guide - How to Request an Expedited Hearing" - California")
![Form I&A5 "Information & Assistance Unit Guide - How to File a Declaration of Readiness to Proceed" - California](https://data.templateroller.com/pdf_docs_html/2325/23254/2325489/form-i-a5-information-assistance-unit-guide-how-to-file-a-declaration-of-readiness-to-proceed-california.png "Form I&A5 "Information & Assistance Unit Guide - How to File a Declaration of Readiness to Proceed" - California")
![Form EPA-1 "Equal Pay Act Complaint" - California](https://data.templateroller.com/pdf_docs_html/1773/17731/1773169/form-epa-1-equal-pay-act-complaint-california.png "Form EPA-1 "Equal Pay Act Complaint" - California")
![Form A-5 "Corporate Resolution Authorizing Application to the Director of Industrial Relations, State of California for a Certificate of Consent to Self-insure Workers' Compensation Liabilities" - California](https://data.templateroller.com/pdf_docs_html/1773/17731/1773130/form-a-5-corporate-resolution-authorizing-application-to-the-director-industrial-relations-state-california-a-certificate-consent-to-self-insure-workers-compensation-liabilities-california.png "Form A-5 "Corporate Resolution Authorizing Application to the Director of Industrial Relations, State of California for a Certificate of Consent to Self-insure Workers' Compensation Liabilities" - California")
![Form A-6 "Agreement and Undertaking for Security Deposit" - California](https://data.templateroller.com/pdf_docs_html/1773/17731/1773131/form-a-6-agreement-and-undertaking-security-deposit-california.png "Form A-6 "Agreement and Undertaking for Security Deposit" - California")
![Form A-4 "Guaranty of Workers' Compensation Liabilities" - California](https://data.templateroller.com/pdf_docs_html/1773/17731/1773132/form-a-4-guaranty-workers-compensation-liabilities-california.png "Form A-4 "Guaranty of Workers' Compensation Liabilities" - California")
![Form S-3 "Corporate Resolution Authorizing Application to the Director of Industrial Relations, State of California for a Certificate of Consent to Self-insure Workers' Compensation Liabilities" - California](https://data.templateroller.com/pdf_docs_html/1773/17731/1773134/form-s-3-corporate-resolution-authorizing-application-to-the-director-industrial-relations-state-california-a-certificate-consent-to-self-insure-workers-compensation-liabilities-california.png "Form S-3 "Corporate Resolution Authorizing Application to the Director of Industrial Relations, State of California for a Certificate of Consent to Self-insure Workers' Compensation Liabilities" - California")
![Form S-6 "Agreement and Undertaking for Security Deposit" - California](https://data.templateroller.com/pdf_docs_html/1773/17731/1773135/form-s-6-agreement-and-undertaking-security-deposit-california.png "Form S-6 "Agreement and Undertaking for Security Deposit" - California")
![Form A-1 "Application for Certificate of Consent to Self-insure as a Private Employer Self-insurer" - California](https://data.templateroller.com/pdf_docs_html/1773/17731/1773137/form-a-1-application-certificate-consent-to-self-insure-as-a-private-employer-self-insurer-california.png "Form A-1 "Application for Certificate of Consent to Self-insure as a Private Employer Self-insurer" - California")
![Form A-2 "Application for Certificate of Consent to Self-insure as a Public Agency Employer Self-insurer" - California](https://data.templateroller.com/pdf_docs_html/1773/17731/1773140/form-a-2-application-certificate-consent-to-self-insure-as-a-public-agency-employer-self-insurer-california.png "Form A-2 "Application for Certificate of Consent to Self-insure as a Public Agency Employer Self-insurer" - California")
![Form S-1 "Group Master Application for Certificate of Consent to Self-insure as a Group Self-insurer" - California](https://data.templateroller.com/pdf_docs_html/1773/17731/1773147/form-s-1-group-master-application-certificate-consent-to-self-insure-as-a-group-self-insurer-california.png "Form S-1 "Group Master Application for Certificate of Consent to Self-insure as a Group Self-insurer" - California")
![Form S-4 "Indemnity Agreement and Power of Attorney" - California](https://data.templateroller.com/pdf_docs_html/1767/17671/1767160/form-s-4-indemnity-agreement-and-power-attorney-california.png "Form S-4 "Indemnity Agreement and Power of Attorney" - California")
![Form S-5 "Agreement of Assumption and Guarantee of Workers' Compensation Liabilities for Group and Affiliate Members" - California](https://data.templateroller.com/pdf_docs_html/1773/17731/1773138/form-s-5-agreement-assumption-and-guarantee-workers-compensation-liabilities-group-and-affiliate-members-california.png "Form S-5 "Agreement of Assumption and Guarantee of Workers' Compensation Liabilities for Group and Affiliate Members" - California")
![Form I&A1 "Information & Assistance Unit Guide - How to File a Workers' Compensation Claim Form" - California](https://data.templateroller.com/pdf_docs_html/2325/23254/2325485/form-i-a1-information-assistance-unit-guide-how-to-file-a-workers-compensation-claim-form-california.png "Form I&A1 "Information & Assistance Unit Guide - How to File a Workers' Compensation Claim Form" - California")
![Form RCI1 "Retaliation Complaint" - California](https://data.templateroller.com/pdf_docs_html/1773/17731/1773193/form-rci-1-retaliation-complaint-california.png "Form RCI1 "Retaliation Complaint" - California")
![Formulario RCI1 "Queja Sobre Represalias" - California (Spanish)](https://data.templateroller.com/pdf_docs_html/1773/17732/1773208/form-rci-1-queja-sobre-represalias-california.png "Formulario RCI1 "Queja Sobre Represalias" - California (Spanish)")
![Formulario DLSE-PW1 "Reclamo De Trabajadores De Obras Publicas" - California (Spanish)](https://data.templateroller.com/pdf_docs_html/1773/17731/1773162/dlse-form-dlse-pw-1-reclamo-de-trabajadores-de-obras-publicas-california.png "Formulario DLSE-PW1 "Reclamo De Trabajadores De Obras Publicas" - California (Spanish)")
![Form DLSE-PW1 "Public Works - Worker Complaint" - California](https://data.templateroller.com/pdf_docs_html/472/4729/472960/dlse-form-pw1-public-works-worker-complaint-california.png "Form DLSE-PW1 "Public Works - Worker Complaint" - California")
![DLSE Form 1 "Initial Report or Claim" - California (Tagalog)](https://data.templateroller.com/pdf_docs_html/1773/17731/1773161/form-1-initial-report-or-claim-california.png "DLSE Form 1 "Initial Report or Claim" - California (Tagalog)")
![DLSE Form 1 "Initial Report or Claim" - California](https://data.templateroller.com/pdf_docs_html/241/2418/241834/dlse-form-1-initial-report-or-claim-california-labor-commissioner-california.png "DLSE Form 1 "Initial Report or Claim" - California")
![Form DLSE8 "Payday Notice" - California](https://data.templateroller.com/pdf_docs_html/2223/22234/2223472/form-dlse8-payday-notice-california.png "Form DLSE8 "Payday Notice" - California")
![Form P-1 "Self-insurer's Profile and Financial Summary Report" - California](https://data.templateroller.com/pdf_docs_html/2085/20852/2085219/form-p-1-self-insurer-s-profile-and-financial-summary-report-california.png "Form P-1 "Self-insurer's Profile and Financial Summary Report" - California")
![Form J-1 "Joint Powers Authority (Jpa) Self-insurer's Profile and Financial Summary Report" - California](https://data.templateroller.com/pdf_docs_html/2085/20852/2085220/form-j-1-joint-powers-authority-jpa-self-insurer-s-profile-and-financial-summary-report-california.png "Form J-1 "Joint Powers Authority (Jpa) Self-insurer's Profile and Financial Summary Report" - California")
![Form I&A19 "Information & Assistance Unit Guide - How to File a Petition Appealing Administrative Director's Independent Medical Review Determination" - California](https://data.templateroller.com/pdf_docs_html/2325/23254/2325494/form-i-a19-information-assistance-unit-guide-how-to-file-a-petition-appealing-administrative-director-s-independent-medical-review-determination-california.png "Form I&A19 "Information & Assistance Unit Guide - How to File a Petition Appealing Administrative Director's Independent Medical Review Determination" - California")
![Form I&A12 "Information & Assistance Unit Guide - How to File a Petition for Reconsideration" - California](https://data.templateroller.com/pdf_docs_html/2325/23254/2325492/form-i-a12-information-assistance-unit-guide-how-to-file-a-petition-for-reconsideration-california.png "Form I&A12 "Information & Assistance Unit Guide - How to File a Petition for Reconsideration" - California")
![Form DAS4A "Division of Apprenticeship Standards Complaint Form" - California](https://data.templateroller.com/pdf_docs_html/2260/22601/2260149/form-das4a-division-of-apprenticeship-standards-complaint-form-california.png "Form DAS4A "Division of Apprenticeship Standards Complaint Form" - California")
![Form A-3A "Private / Public Interim Application" - California](https://data.templateroller.com/pdf_docs_html/1773/17731/1773126/form-a-3a-private-public-interim-application-california.png "Form A-3A "Private / Public Interim Application" - California")
![Form A-3B "Application for Permanent Certificate of Consent to Self-insure for Interim Self-insurer" - California](https://data.templateroller.com/pdf_docs_html/1773/17731/1773127/form-a-3b-application-permanent-certificate-consent-to-self-insure-interim-self-insurer-california.png "Form A-3B "Application for Permanent Certificate of Consent to Self-insure for Interim Self-insurer" - California")
![Form S-2B "Application for Affiliate Certificate of Consent to Self-insure as a Member of a Group Self-insurer" - California](https://data.templateroller.com/pdf_docs_html/1773/17731/1773136/form-s-2b-application-affiliate-certificate-consent-to-self-insure-as-a-member-a-group-self-insurer-california.png "Form S-2B "Application for Affiliate Certificate of Consent to Self-insure as a Member of a Group Self-insurer" - California")
![Form S-2A "Group Affiliate Member Interim Application" - California](https://data.templateroller.com/pdf_docs_html/1773/17731/1773141/form-s-2a-group-affiliate-member-interim-application-california.png "Form S-2A "Group Affiliate Member Interim Application" - California")
![WCAB Form 24 "Pre-trial Conference Statement" - California](https://data.templateroller.com/pdf_docs_html/2193/21932/2193224/wcab-form-24-pre-trial-conference-statement-california.png "WCAB Form 24 "Pre-trial Conference Statement" - California")
![Form 33 "Safety and Health Program Assessment Worksheet" - California](https://data.templateroller.com/pdf_docs_html/162/1620/162025/form-33-safety-and-health-program-assessment-worksheet-california.png "Form 33 "Safety and Health Program Assessment Worksheet" - California")
![DWC/WCAB Form 37 "Notice of Dismissal of Attorney" - California](https://data.templateroller.com/pdf_docs_html/2193/21932/2193231/dwc-wcab-form-37-notice-of-dismissal-of-attorney-california.png "DWC/WCAB Form 37 "Notice of Dismissal of Attorney" - California")
![Form DWC-AU-906 "Audit Complaint Form" - California](https://data.templateroller.com/pdf_docs_html/2193/21932/2193237/form-dwc-au-906-audit-complaint-form-california.png "Form DWC-AU-906 "Audit Complaint Form" - California")
![Form OSHAB-316 "Subpoena Re Deposition" - California](https://data.templateroller.com/pdf_docs_html/2223/22234/2223467/form-oshab-316-subpoena-re-deposition-california.png "Form OSHAB-316 "Subpoena Re Deposition" - California")
