Free DWC Application for Adjudication of Claim Template – Download Now!
The DWC Application for Adjudication of Claim is a legal form used in workers’ compensation cases to formally dispute a claim. If an injured worker and their employer or insurance company cannot agree on a settlement, this application is filed to request a hearing before an administrative law judge.
When to Use This Form
- If your workers’ compensation claim has been denied or delayed.
- When there is a dispute over medical treatment or benefits.
- If you need a formal decision on your case from a judge.
What’s Included in the Application?
- Injury details (date, type, and circumstances of the injury).
- Employer and insurance company information.
- Disputed issues, such as unpaid benefits or denied medical care.
- Requested compensation and claim details.
Who Can File This Form?
- Injured workers (claimants) seeking workers’ compensation benefits.
- Legal representatives acting on behalf of the injured worker.
What Happens After Filing?
After the form is submitted to the Division of Workers’ Compensation (DWC):
- A hearing is scheduled, where both sides present evidence.
- A judge reviews the case and makes a final decision.
Template Categories
California
General
How to Use the DWC Application for Adjudication of Claim Template
- Click the download button and provide your email address
- Receive the form directly in your inbox instantly.
- Download the form, complete it and send it to the DWC.
Get your free template to start the legal process for your workers’ compensation claim!
Related Templates
Sample IME/QME Report Template
Sample IME/QME Report TemplateAn Independent Medical Examination (IME) report or a Qualified Medical Evaluation (QME) is a vital document used to provide an unbiased medical opinion in legal, insurance, or worker's compensation cases. These reports are diligently...
Free DWC Form PR-4: Primary Treating Physician’s P&S Report Template
Free DWC Form PR-4: Primary Treating Physician’s P&S Report TemplateThe DWC form PR-4 or the Primary Treating Physician’s Permanent and Stationary Report (P&S Report) is an important document in California workers' compensation cases, submitted when an...
Request for Factual Correction of an Unrepresented Panel QME Report (QME Form 37)
Request for Factual Correction of an Unrepresented Panel QME Report (Form 37) The Request for Factual Correction of an Unrepresented Panel QME Report (QME Form 37) is an essential document in California workers' compensation cases. It allows an unrepresented injured...
Free DWC Form RFA to Request Authorization for Medical Treatment
Free DWC Form RFA to Request Authorization for Medical TreatmentThe DWC Form RFA or the Request Authorization for Medical Treatment Form is used in California workers' compensation cases to request prior approval from an insurance company or claims administrator...
QME Form 104 – Reappointment Application as a Qualified Medical Evaluator
QME Form 104 – Reappointment Application as a Qualified Medical EvaluatorThe Reappointment Application as Qualified QME (QME Form 104) is a much-required document for physicians in California seeking to renew their position as a Qualified Medical Evaluator (QME). This...
QME Replacement Panel Request Form-Download for Free!
QME Replacement Panel Request Form-Download for Free!The Replacement Panel Request Form is a significant document in California’s workers' compensation system. It allows parties involved in a claim to request a new panel of Qualified Medical Examiners (QMEs) when the...
Download QME Form 105 for Free – Complete Your QME Panel Request
Download QME Form 105 for Free – Complete Your QME Panel RequestThe Request for Qualified Medical Evaluator (QME) Panel Form 105 is a crucial document used in California workers' compensation cases to request a panel of three Qualified Medical Evaluators (QMEs). This...
QME Notice of Unavailability (Form 109) – Free Template Download
QME Notice of Unavailability (Form 109) – Free Template DownloadThe QME Notice of Unavailability (Form 109) is an essential form used in California workers' compensation cases to notify the Division of Workers' Compensation (DWC) Medical Unit when a Qualified Medical...
Download Free QME Form 121 – Protection of Mental Health Record
Download Free QME Form 121 – Protection of Mental Health RecordThe QME Form 121 is an important document used in California workers’ compensation cases to ensure the confidentiality of an injured worker’s mental health records. A Qualified Medical Evaluator (QME) must...
Free QME Form 120 Template – Download Now!
Free QME Form 120 Template – Download Now!The Voluntary Directive for Alternate Service of Medical-Legal Evaluation Report on Disputed Injury to Psyche (Form 120) is used in California workers' compensation cases when an injured worker wants their psychological injury...