What this form is for
Workers' compensation claim form - - -
Official file
Published by the Division of Workers' Compensation. This page does not replace the form — it points at the state's PDF and, where the form is what a panel actually ruled on, quotes that ruling.
How to fill a DWC form →Source: dir.ca.gov/dwc/forms.html. Unofficial guide — the PDF on that site is the form.
What the Appeals Board did with this
Decisions of the Workers' Compensation Appeals Board that turned on this kind of filing. Each quotes the passage it turned on and links to the official PDF.
- ADJ18656111 · 2026-06-26 · Bakersfield District OfficeAOE/COEdefendant prevailed
Determinative passage · p.1Defendant seeks reconsideration of the Findings of Fact issued on March 3, 2026, wherein the workers' compensation administrative law judge ("WCJ") found that defendant did not prove that decedent's death was proximately caused by intoxication. Defendant asserts that the WCJ erred because the evidence supports the opinion of the Qualified Medical Examiner ("QME") that intoxication was a proximate or substantial cause of the injury.
The Appeals Board agreed with the WCJ that defendant did not prove by a preponderance of the evidence that decedent's intoxication was a proximate or substantial cause of the injury, due to lack of concrete evidence and reliance on speculative assumptions in the QME report.
Official decision · page 1 → - ADJ13582881 · 2026-06-26 · Long Beach District OfficeAOE/COEapplicant prevailed
Determinative passage · p.1Defendant seeks reconsideration of a workers' compensation administrative law judge's (WCJ) Findings and Award of March 16, 2026, wherein it was found that while employed as an assistant manager applicant sustained industrial injury in the form of a hernia and to the low back, causing the need for further medical treatment. Industrial injury to the hernia had been accepted by the defendant, but injury to the low back was contested. All other issues including date of injury, temporary disability, and permanent disability were deferred.
The Appeals Board found substantial evidence supporting industrial injury to the low back based on the entire medical record and credible applicant testimony, favoring the treating physician's opinions over the PQME Dr. Shah's contrary opinion.
Official decision · page 1 → - ADJ18031412 · 2026-06-26 · San Diego District OfficeAOE/COEdefendant prevailed
Determinative passage · p.1Lien claimant Medland Medical seeks reconsideration of the Findings and Order issued by the workers' compensation administrative law judge (WCJ) on April 6, 2026. Therein, the WCJ found that, while employed as a Machine Operator/Packer, applicant claims to have sustained injury arising out of and occurring in the course of employment (AOE/COE) to her bilateral arms, bilateral hands, back, bilateral hips, and bilateral legs. The WCJ further found that the case in chief settled via Compromise and Release with an Order Approving issuing October 14, 2025; that lien claimant did not meet the burden of proof on the injury AOE/COE, such that the lien is disallowed in its entirety. Based on these findings, the WCJ ordered that lien claimant's lien be disallowed in its entirety.
The lien claimant failed to meet the burden of proof by a preponderance of the evidence to establish injury AOE/COE based on the medical record and evidentiary record submitted. The ultimate conclusion of industrial causation was deferred to the Trier of Fact, and the WCJ found no sufficient evidence to support the lien claimant's claim.
Official decision · page 1 → - ADJ14972494 · 2026-06-23 · Van Nuys District OfficeAOE/COEapplicant prevailed
Determinative passage · p.1Defendant seeks reconsideration of the February 3, 2026 Findings of Fact, Award and Order (F&A) issued by the workers' compensation administrative law judge (WCJ), wherein the WCJ found that while employed by defendant as a chief negotiator for the nurses' union, from February 4, 2005 to July 13, 2021, applicant sustained injury arising out of and occurring in the course of employment to her "internal" and eyes/vision, and claimed injury to various parts.
The WCJ's finding of industrial injury to the eyes/vision is supported by substantial medical evidence including the ophthalmology QME Dr. Sami's opinion, the internal medicine AME Dr. Grodan's deferral to Dr. Sami, credible applicant testimony, and contemporaneous treating records. The Report on Reconsideration supplies the reasoning required under Labor Code section 5313, curing any deficiency in the original Opinion on Decision.
Official decision · page 1 →