Documents Available for Download by Injured Workers
Medical Mileage Reimbursement Form

To be completed and submitted by fax or mail when you would like to request reimbursement for medical mileage.

Designation of Treating Physician Form

To be completed and submitted by fax or mail when you would like to change your treating physician.

Request for Qualified Medical Evaluator (QME) Panel
To Request a Qualified Medical Evaluator (QME) Panel from the State Medical Unit, use the form above, if you are not represented by an attorney.

Claim Form (DWC-1)
Employee's Claim for Workers' Compensation Benefits. Fill out the top portion and return to your employer.
Employee's Permanent Disability Questionnaire (DEU 100)
This form is to be completed by the injured worker. The completed form is then given to the Panel QME physician at the time of the evaluation.


Additional information about workers’ compensation benefits may be obtained at the State of California Division of Workers’ Compensation (DWC) web site located at:

The DWC web site provides extensive information about workers’ compensation, such as:

• Workers’ Compensation in California: A Guidebook for Injured Workers.
• Fact Sheets – provide information about specific benefits and procedures.
• Injured Worker Guides – detailed instructions on how to complete forms.
• Forms – you may need some of these forms during your claim.

In additional to the web site, the DWC has Information and Assistance (I&A) Officers can be reached at:

San Luis Obispo, CA (805) 596-4159

For recorded information from the DWC and a list of their offices, you may call (800) 736-7401.


Labor Code Section 5401.7 FRAUD WARNING: "Any person who makes or causes to be made any knowingly false or fraudulent material statement or material representation for the purpose of obtaining or denying workers' compensation benefits or payments is guilty of a felony."