California Department of Industrial Relations Forms
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Form EPA-1 "Equal Pay Act Complaint" - California
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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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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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332 KB
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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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508 KB
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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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1 MB
6 pages
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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
5 pages
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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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50 votes
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1 MB
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Form S-4 "Indemnity Agreement and Power of Attorney" - California
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68 votes
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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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46 votes
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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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1 MB
9 pages
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Form 1 "Initial Report or Claim" - California (Tagalog)
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31 votes
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1 MB
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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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1 MB
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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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44 votes
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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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Form 105 "Request for Qualified Medical Evaluator Panel" - California
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61 votes
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2 MB
3 pages
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Form 110 "Qme Appointment Notification Form" - California
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35 votes
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1 MB
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Cal/OSHA Form 300 Appendix A "Log of Work-Related Injuries and Illnesses" - California
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12 votes
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499 KB
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Form DIA510 "Notice of Employee Death" - California
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71 votes
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140 KB
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Form 5021 "Doctors First Report of Occupational Injury or Illness" - California
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75 votes
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114 KB
3 pages
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Form 9783 "Predesignation of Personal Physician" - California
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56 votes
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2 MB
2 pages
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Form 5020 "Employer's Report of Occupational Injury or Illness" - California
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38 votes
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267 KB
4 pages
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Form A4-50 "Application for a Certificate of Consent to Administer Workers' Compensation Self Insurance Claims" - California
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69 votes
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1 MB
6 pages
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Form 10214 "Compromise and Release" - California
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96 votes
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9 pages
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Form A4-100 "Application for a Self Insurance Administrator's Examination" - California
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14 votes
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Form A-1-131 "Public Works Payroll Reporting Form" - California
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22 votes
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229 KB
2 pages
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"Hazard Assessment Checklist" - California
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7 votes
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86 KB
20 pages
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"Subpoena Duces Tecum" - California
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79 votes
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127 KB
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"Report of Transfer of Records" - California
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87 votes
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"Resolution of Agreement of Parental Assumption and Guarantee" - California
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32 votes
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![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 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)")
![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 "Form 1 "Initial Report or Claim" - California (Tagalog)")
![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")
![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")
![Form 105 "Request for Qualified Medical Evaluator Panel" - California](https://data.templateroller.com/pdf_docs_html/335/3358/335851/form-105-request-qualified-medical-evaluator-panel-california.png "Form 105 "Request for Qualified Medical Evaluator Panel" - California")
![Form 110 "Qme Appointment Notification Form" - California](https://data.templateroller.com/pdf_docs_html/103/1039/103952/form-110-qme-appointment-notification-form-california.png "Form 110 "Qme Appointment Notification Form" - California")
![Cal/OSHA Form 300 Appendix A "Log of Work-Related Injuries and Illnesses" - California](https://data.templateroller.com/pdf_docs_html/1/14/1439/cal-osha-form-300-appendix-a-log-of-work-related-injuries-and-illnesses-california.png "Cal/OSHA Form 300 Appendix A "Log of Work-Related Injuries and Illnesses" - California")
![Form DIA510 "Notice of Employee Death" - California](https://data.templateroller.com/pdf_docs_html/74/744/74467/form-dia-510-notice-employee-death-california.png "Form DIA510 "Notice of Employee Death" - California")
![Form 5021 "Doctors First Report of Occupational Injury or Illness" - California](https://data.templateroller.com/pdf_docs_html/74/744/74410/form-5021-doctors-first-report-occupational-injury-or-illness-california.png "Form 5021 "Doctors First Report of Occupational Injury or Illness" - California")
![Form 9783 "Predesignation of Personal Physician" - California](https://data.templateroller.com/pdf_docs_html/341/3417/341740/form-9783-predesignation-personal-physician-california.png "Form 9783 "Predesignation of Personal Physician" - California")
![Form 5020 "Employer's Report of Occupational Injury or Illness" - California](https://data.templateroller.com/pdf_docs_html/81/815/81507/form-5020-employer-s-report-occupational-injury-or-illness-california.png "Form 5020 "Employer's Report of Occupational Injury or Illness" - California")
![Form A4-50 "Application for a Certificate of Consent to Administer Workers' Compensation Self Insurance Claims" - California](https://data.templateroller.com/pdf_docs_html/1765/17659/1765971/form-a-4-50-application-a-certificate-consent-to-administer-workers-compensation-self-insurance-claims-california.png "Form A4-50 "Application for a Certificate of Consent to Administer Workers' Compensation Self Insurance Claims" - California")
![Form 10214 "Compromise and Release" - California](https://data.templateroller.com/pdf_docs_html/103/1039/103987/form-10214-compromise-and-release-california.png "Form 10214 "Compromise and Release" - California")
![Form A4-100 "Application for a Self Insurance Administrator's Examination" - California](https://data.templateroller.com/pdf_docs_html/2020/20200/2020060/form-a4-100-application-for-a-self-insurance-administrator-s-examination-california.png "Form A4-100 "Application for a Self Insurance Administrator's Examination" - California")
![Form A-1-131 "Public Works Payroll Reporting Form" - California](https://data.templateroller.com/pdf_docs_html/13/134/13408/form-a-1-131-public-works-payroll-reporting-form-california.png "Form A-1-131 "Public Works Payroll Reporting Form" - California")
!["Hazard Assessment Checklist" - California](https://data.templateroller.com/pdf_docs_html/175/1754/175412/hazard-assessment-checklist-california.png ""Hazard Assessment Checklist" - California")
!["Subpoena Duces Tecum" - California](https://data.templateroller.com/pdf_docs_html/1765/17654/1765452/subpoena-duces-tecum-california.png ""Subpoena Duces Tecum" - California")
!["Report of Transfer of Records" - California](https://data.templateroller.com/pdf_docs_html/1773/17731/1773139/report-transfer-records-california.png ""Report of Transfer of Records" - California")
!["Resolution of Agreement of Parental Assumption and Guarantee" - California](https://data.templateroller.com/pdf_docs_html/1767/17671/1767162/resolution-of-agreement-of-parental-assumption-and-guarantee-california.png ""Resolution of Agreement of Parental Assumption and Guarantee" - California")
