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60
![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 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)")
![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/payday-notice.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 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 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")
![DWC-AD Form 100 "Employee's Disability Questionnaire" - California](https://data.templateroller.com/pdf_docs_html/2193/21932/2193239/dwc-ad-form-100-employee-s-disability-questionnaire-california.png "DWC-AD Form 100 "Employee's Disability Questionnaire" - 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")
![DWC Form 280 "Petition for Change of Primary Treating Physician" - California](https://data.templateroller.com/pdf_docs_html/2193/21932/2193240/dwc-form-280-petition-for-change-of-primary-treating-physician-california.png "DWC Form 280 "Petition for Change of Primary Treating Physician" - 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")
![Instructions for QME Form 105 "Request for Qualified Medical Evaluator Panel (Unrepresented Employee)" - California](https://data.templateroller.com/pdf_docs_html/2193/21932/2193213/instructions-for-qme-form-105-request-for-qualified-medical-evaluator-panel-unrepresented-employee-california.png "Instructions for QME Form 105 "Request for Qualified Medical Evaluator Panel (Unrepresented Employee)" - California")
![Instructions for QME Form 106 "Request for Qme Panel Under Labor Code 4062.2 Represented - for Injuries Occurring Prior to January 1, 2005" - California](https://data.templateroller.com/pdf_docs_html/2193/21932/2193212/instructions-for-qme-form-106-request-for-qme-panel-under-labor-code-4062-2-represented-for-injuries-occurring-prior-to-january-1-2005-california.png "Instructions for QME Form 106 "Request for Qme Panel Under Labor Code 4062.2 Represented - for Injuries Occurring Prior to January 1, 2005" - 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 5021 "Doctors First Report of Occupational Injury or Illness" - California
Size: 114 KB
3 pages
