The California WCAB Compromise and Release, filed on DWC-CA form 10214(c) (revision dated 11/2008), is a nine-page settlement document an injured worker uses to resolve a California workers’ compensation claim for a single lump sum payment in exchange for releasing the employer and insurance carrier from future liability. The form must be approved by a workers’ compensation administrative law judge at the Workers’ Compensation Appeals Board under Labor Code §5001 before it has any legal effect.
The Division of Workers’ Compensation reports that more than 50% of all California work injury cases close through a Compromise and Release rather than a Stipulated Award, and the DWC’s annual case-closing data shows tens of thousands of C&Rs filed each year. A single wrong entry on Paragraph 1, Paragraph 7, or the Medicare paragraphs can void the settlement, trigger a rejection at the walk-through window, or leave you personally responsible for medical bills you thought were closed.
- 📝 How to fill in every box on DWC-CA 10214(c) line by line, including the body-parts paragraph and the settlement-breakdown paragraph
- ⚖️ How to file the C&R through EAMS, JET File, walk-through, or mail, and what proof of filing to keep
- 🏥 How Medicare, MSAs, Medi-Cal liens, and child support liens change what you write on the form
- 💵 How three real injured workers — Maria, Carlos, and Janet — fill out their own C&Rs from start to finish
- 🚫 The 12 most common C&R mistakes and the exact consequence each one triggers at the WCAB
What the Form Is and Who Must File It
DWC-CA form 10214(c) Compromise and Release is the official California settlement form adopted under 8 CCR §10205.2, which incorporates the 11/2008 revision by reference. The form converts an open workers’ compensation claim into a one-time lump sum, ending the carrier’s duty to pay future temporary disability, permanent disability, and lifetime medical care for the body parts and dates of injury listed inside the four corners of the document. Once a workers’ compensation administrative law judge signs the Order Approving Compromise and Release (OACR), the settlement is final under Labor Code §5001 and can only be reopened in narrow situations like fraud, mutual mistake, or newly discovered evidence under Labor Code §5803.
The form is filed by the applicant (the injured worker) and the defendants (the employer and the workers’ compensation insurance carrier or third-party administrator). Pro se workers, applicant attorneys, defense attorneys, claims adjusters, and even the dependents of a deceased worker (using the parallel DWC-CA 10214(d) dependency form) all use the 10214(c) when settling a non-fatal claim. The form is mandatory; the parties cannot draft a homemade settlement on plain paper, because the WCAB rules of practice require this exact OCR-readable form so the document scans correctly into the Electronic Adjudication Management System.
You must file a 10214(c) when you want to close out indemnity, future medical, or both, or when the carrier denied the claim and you want a “wash-out” settlement that resolves the disputed claim with no admission of liability. You should not use this form when you only want to fix the percentage of permanent disability and keep future medical open — that is a Stipulated Findings & Award on form DWC-CA 10214(b). Picking the wrong form is the single most common pre-filing error and forces parties to redraft from scratch.
Before You Start: Documents and Information You Need
Filling out a Compromise and Release without the right documents in front of you almost guarantees a rejected walk-through or, worse, a settlement that gets approved with the wrong numbers locked in. Gather every item below before you open the PDF, because each one feeds a specific paragraph on the form. Missing even one document can stall approval for weeks while the WCJ requests a “Notice of Intention to Disapprove.”
- Your ADJ case number from EAMS. This 7-digit number is what the WCAB uses to find your file; without it, the form cannot be matched to your case and the clerk will reject the filing at intake.
- Date of injury or cumulative trauma period. The date drives the statute of limitations under Labor Code §5405 and the applicable PD rating schedule; an incorrect date can void the release.
- Average weekly wage and earnings at time of injury. Labor Code §5003 requires this on the face of the C&R; understating wages can later be argued as fraud and undo the settlement.
- Every medical-legal report (QME, AME, PTP). The reports support the body parts listed in Paragraph 1 and the impairment rating used to value the case; missing reports invite WCJ skepticism on adequacy.
- A current Medicare status letter or CMS-approved MSA. Medicare beneficiaries and “reasonable expectation” cases over $250,000 must protect Medicare’s interests on the C&R, or CMS may deny future treatment for the injury.
- All lien claimants and lien amounts. Medical providers, EDD, Medi-Cal, and child support liens must be addressed on the C&R; an unresolved lien stops approval cold.
- Photo identification for the applicant. The signature on Paragraph 9 must be witnessed by two disinterested adults or notarized, and the witness or notary will check ID under Labor Code §5003.
- Attorney fee disclosure or Labor Code §4906(h) declaration. Required if the applicant is represented; the WCJ cannot approve fees without it.
- Proof of dependency (if applicable). A spouse or minor children may have separate claims that survive the C&R; without proof, the judge may demand a guardian ad litem.
- Settlement Conference statement or DOR. Many WCJs require a Pre-Trial Conference Statement or Declaration of Readiness to Proceed before approving a walk-through.
Where to Get the Form and How to Access It
The official, current version of DWC-CA form 10214(c) is hosted on the Division of Workers’ Compensation forms page; download it directly from the DWC EAMS forms library so you have the OCR-coded version that EAMS can read. The form is a fillable PDF, but it is not an Acrobat-XFA form, so any modern PDF reader (Adobe, Preview, Foxit) can complete it. Avoid third-party reseller sites, because they often host the older 1/2007 revision, which the WCAB will reject.
Print the form on plain white 8.5 × 11 paper, single-sided, with no scaling. The OCR squares in the corners of every page must remain crisp; if you scale the form to “fit to page,” the squares move and EAMS cannot index the document. Use black ink only for handwritten entries — blue ink and pencil scan poorly and are routinely rejected at the District Office filing window.
If you are filing electronically, save the completed PDF as a single flattened file under 5 MB and upload it through the JET File system (for trading partners) or through the e-Form filing portal for represented and pro se filers with EAMS accounts. Walk-through filers bring three originals plus the OACR to the District Office. Mail filers must send the original plus two copies to the District Office where the case is venued, with a self-addressed stamped envelope for the conformed copy.
Step-by-Step: How to Fill Out DWC-CA 10214(c) Line by Line
The form runs nine pages with twelve numbered paragraphs, an attachment section, signature blocks, and an Order Approving Compromise and Release. Every numbered paragraph below is the exact label printed on the 11/2008 revision of the form; do not paraphrase or renumber. The Step-by-Step section is the spine of the article, so each major paragraph gets its own H3 with the six expansion elements: plain English, how to answer, an example entry, a nuance, a mistake with consequence, and a misconception correction.
Case Caption: Applicant, Employer, Insurance Carrier, and Case Number
What it asks in plain English. The caption at the top of page 1 asks for the injured worker’s name as the Applicant, the employer’s legal name, the insurance carrier or self-insured administrator, and the WCAB ADJ case number assigned by EAMS.
How to answer it. Type the applicant’s full legal name in LASTNAME, FIRSTNAME MIDDLE format in all capital letters. Enter the employer exactly as it appears on the DWC-1 claim form. Enter the carrier’s full legal name (e.g., STATE COMPENSATION INSURANCE FUND, not SCIF). Place the seven-digit ADJ number in the case-number box; if there are multiple companion cases, list each ADJ number separated by commas.
Example entry. Maria Lopez, who hurt her back lifting boxes at a grocery warehouse, writes LOPEZ, MARIA ELENA as Applicant, FRESH MART INC. as Employer, ZURICH AMERICAN INSURANCE COMPANY as Carrier, and ADJ1234567 as the case number.
Nuance. If the employer was sold, merged, or used a DBA at the time of injury, list the legal entity that held the workers’ comp policy on the date of injury, then add “dba [trade name]” in parentheses. If the carrier changed mid-claim, list the current handling carrier, because that is who pays the lump sum.
Common mistake and consequence. Filers often write a nickname or the employer’s marketing name instead of the legal entity. The District Office computer cannot match a non-legal name to the policy, so the WCJ issues a Notice of Intention to Disapprove, costing 30 days of delay.
Misconception. People believe the case caption is “just for show.” It is not — it defines exactly who is bound by the release, and a missing or misspelled defendant remains free to be sued later, defeating the whole purpose of a wash-out.
Paragraph 1: Date(s) of Injury and Body Parts Injured
What it asks in plain English. Paragraph 1 asks for the specific date of injury (or the cumulative trauma date range) and every body part the worker is settling.
How to answer it. Write the date as MM/DD/YYYY. For a cumulative trauma, write CT [start date] through [end date]. List body parts using the same anatomical terms the AMA Guides 5th Edition uses: lumbar spine, cervical spine, right shoulder, left knee, psyche, sleep, internal (GI), hypertension.
Example entry. Carlos Mendoza, a roofer with a fall, writes DOI: 06/12/2024 and lists lumbar spine, right shoulder, right wrist, head, and psyche (sleep and depression as compensable consequences).
Nuance. Always include compensable-consequence body parts (sleep, psyche, sexual dysfunction, GI from medications) even if they were not separately rated; otherwise they are not released and the worker can later open a new claim for them.
Common mistake and consequence. Pro se filers list only the “main” injury (e.g., back) and leave off psyche or sleep. The carrier later refuses to pay for psyche treatment, and the worker has no way to enforce coverage because psyche was never part of the release.
Misconception. Many believe “general body” or “all parts injured” is enough. WCJs routinely reject vague body-part language because the WCAB en banc decision in Jefferson v. Compass Vision and longstanding practice require specific anatomical listing.
Paragraph 2: Parts of Body Claimed by Applicant That Are Disputed
What it asks in plain English. Paragraph 2 lists body parts the applicant claims but the carrier disputes.
How to answer it. List each disputed part on its own line. If the carrier accepted everything, write “None — all claimed parts accepted.” If the case is fully denied, write “All parts of body listed in Paragraph 1 are disputed; this is a denied-claim wash-out settlement.”
Example entry. Janet Park, a nurse with a denied COVID claim, writes “All claimed body parts (respiratory, cardiac, psyche) are disputed; defendants deny industrial causation.”
Nuance. Settling disputed parts at a discount is normal, but the C&R must say “without admission of liability” if the carrier wants to preserve denial language for any subrogation or third-party action.
Common mistake and consequence. Filers leave Paragraph 2 blank when there is a real dispute. The WCJ then assumes everything is accepted and may demand higher consideration, delaying approval.
Misconception. Workers think disputed parts cannot be settled. They can — that is the entire point of a compromise — but the form must clearly mark them as disputed.
Paragraph 3: Earnings at Time of Injury
What it asks in plain English. Paragraph 3 asks for the average weekly wage used to calculate temporary and permanent disability rates under Labor Code §4453.
How to answer it. Enter the gross weekly wage rounded to the nearest cent. If the worker earned the statutory maximum, write the maximum AWW for the year of injury (e.g., $1,619.15 for a 2024 injury). For irregular earners, calculate AWW from the year before injury divided by 52.
Example entry. Maria’s payroll shows $36,400 in the year before her 9/15/2024 injury, so she enters $700.00 as her AWW.
Nuance. Tips, bonuses, room-and-board, and concurrent employment all count toward AWW under Labor Code §4453.1; leaving them out understates benefits and may invalidate the settlement.
Common mistake and consequence. Filers enter net (after-tax) wages instead of gross. The PD calculation comes out low, the settlement looks inadequate, and the WCJ disapproves under the WCAB’s adequacy standard.
Misconception. Many believe AWW is just a formality. It is not — it controls the temporary disability rate, the PD rate, and the life pension threshold, and the WCJ will compare it against the settlement amount.
Paragraph 4: Permanent Disability Indemnity Paid to Date
What it asks in plain English. Paragraph 4 asks how many weeks of PD advances the carrier has already paid.
How to answer it. Pull the benefit printout from the carrier and enter the total dollars paid, the weekly rate, and the number of weeks. Format: “$X paid at $Y per week for Z weeks through MM/DD/YYYY.”
Example entry. Carlos’s printout shows “$12,560 paid at $290.00/week for 43.31 weeks through 04/30/2026.”
Nuance. PD advances reduce the lump sum the carrier owes at settlement; if you forget to credit them, you double-count and the WCJ will catch it.
Common mistake and consequence. Filers list temporary disability instead of permanent disability. The numbers don’t match the benefit printout, and the WCJ kicks the file back for correction.
Misconception. Workers think PD advances are “free money.” They are not — they are credits against the final settlement amount.
Paragraph 5: Medical Treatment Provided to Date
What it asks in plain English. Paragraph 5 asks who treated the worker and what was paid.
How to answer it. List the primary treating physician, the medical network (MPN), and the total dollar amount paid for medical so far. If unknown, write “Approximately $[amount]; full payment ledger attached as Exhibit A.”
Example entry. Janet writes “Treatment provided through Kaiser Permanente MPN; total paid to date approximately $48,200; itemized ledger attached.”
Nuance. If treatment was self-procured because the carrier denied the claim, list those providers separately and address reimbursement in Paragraph 7.
Common mistake and consequence. Filers leave Paragraph 5 blank, prompting the WCJ to question whether the worker got adequate care, which can trigger a continuance for a fairness hearing.
Misconception. People assume medical history is private. It is not in a comp case — the C&R is a public WCAB document, and medical disclosure is required for adequacy review.
Paragraph 6: Reason for Compromise
What it asks in plain English. Paragraph 6 explains why the parties are settling rather than litigating.
How to answer it. Write a short, specific narrative covering AOE/COE disputes, apportionment under Labor Code §4663, credibility issues, statute-of-limitations defenses, or the desire to close future medical exposure.
Example entry. Maria’s reason reads “Parties dispute the extent of permanent disability and apportionment to non-industrial degenerative disc disease per the QME report of Dr. Singh dated 02/14/2026; parties wish to avoid the cost and uncertainty of trial.”
Nuance. Vague language like “to buy peace” is disfavored; WCJs want specific, file-grounded reasons that tie to actual evidence.
Common mistake and consequence. Filers write a single sentence with no medical citation. The WCJ issues a Notice of Intention demanding a supplemental statement of reason, delaying approval by weeks.
Misconception. Workers think the “reason for compromise” can be left blank if both sides agree. It cannot — it is mandatory under Labor Code §5001 so the judge can assess adequacy.
Paragraph 7: Settlement Amount and Breakdown
What it asks in plain English. Paragraph 7 is the money paragraph: total settlement, less credits, less attorney fees, less liens, equals the net to the applicant.
How to answer it. Enter the gross settlement, then itemize: PD advances credit, attorney fee, medical-legal liens, child support liens, EDD lien, Medi-Cal lien, MSA funding amount, and finally the net check to the applicant.
Example entry. Carlos’s breakdown reads “Total: $95,000.00. Less PD credit: $12,560.00. Less attorney fee at 15%: $14,250.00. Less Medi-Cal lien: $3,200.00. Less MSA seed funding: $18,000.00. Net to applicant: $46,990.00.”
Nuance. Attorney fees are presumptively 15% under longstanding WCAB Policy and Procedural Manual practice; higher percentages require a separate Petition for Increased Attorney’s Fees with detailed justification.
Common mistake and consequence. Filers list a gross number with no breakdown. The WCJ cannot determine adequacy or fee reasonableness and rejects the settlement.
Misconception. Workers think the gross number is what they get. It is not — liens, fees, and credits routinely cut the net check by 30–50%.
Paragraph 8: Medicare and Medicare Set-Aside Language
What it asks in plain English. Paragraph 8 (and the standard MSA addendum) addresses Medicare’s interests under the Medicare Secondary Payer statute.
How to answer it. Disclose whether the applicant is a Medicare beneficiary, has applied for SSDI, or has a “reasonable expectation” of Medicare entitlement within 30 months. If the case meets CMS review thresholds ($25,000 for current beneficiaries, $250,000 for reasonable-expectation cases), attach the CMS-approved MSA and identify the funding amount and administrator.
Example entry. Janet, age 63 and a Medicare beneficiary, attaches a CMS approval letter dated 03/05/2026 for an MSA of $67,400.00 to be self-administered.
Nuance. Even below CMS thresholds, the parties must still “consider Medicare’s interests”; many WCJs require a non-submit MSA opinion letter for cases between $5,000 and $25,000.
Common mistake and consequence. Filers ignore Medicare entirely. CMS later denies treatment for the injury, and the worker pays out of pocket for the rest of life.
Misconception. Workers believe MSAs are optional. They are not for Medicare beneficiaries — failing to fund one transfers the cost of injury-related care from the carrier to the federal government, which is exactly what the MSP statute prohibits.
Paragraph 9: Signatures, Witnesses, and Notarization
What it asks in plain English. Paragraph 9 is the signature block; the applicant signs in front of two disinterested adult witnesses or a notary public, as required by Labor Code §5003.
How to answer it. The applicant signs and dates in blue or black ink. Two adults who are not parties, attorneys, or family members sign as witnesses with printed names and addresses, or a notary acknowledges the signature with a California all-purpose acknowledgment.
Example entry. Maria Elena Lopez signs and dates 05/15/2026; her neighbors David Chen and Aisha Williams sign as witnesses with their home addresses below.
Nuance. A spouse, child, or attorney cannot serve as a disinterested witness; doing so voids the signature block, and the WCJ will require a fresh execution.
Common mistake and consequence. Filers use one witness and a notary, or use the attorney as a witness. The clerk rejects the form at intake, costing another trip to the District Office.
Misconception. People think electronic signatures are acceptable. They are not on the 10214(c) — the WCAB requires wet-ink signatures or notarized acknowledgments.
Paragraph 10: Attorney Fee Approval and §4906(h) Declaration
What it asks in plain English. Paragraph 10 asks the WCJ to approve the attorney’s fee under Labor Code §4906.
How to answer it. State the fee dollar amount, the percentage, and attach the §4906(h) declaration disclosing any non-attorney fee referrals.
Example entry. “Applicant’s attorney requests approval of $14,250.00 (15% of $95,000.00) pursuant to Labor Code §4906.”
Nuance. For pro se applicants, write “Applicant is unrepresented; no attorney fee.”
Common mistake and consequence. Represented filers omit the §4906(h) declaration. The WCJ disapproves the fee until it is filed.
Misconception. Workers think the attorney fee comes from “somewhere else.” It does not — it is deducted from the gross settlement.
Paragraphs 11–12 and the Addendum
What they ask in plain English. Paragraph 11 lists “additional terms” (e.g., resignation, voluntary quit, confidentiality), and Paragraph 12 lists liens. The standard MSA/Medicare addendum and any custom addenda attach here.
How to answer them. Spell out every special term in plain language. List every lien claimant by name, lien number, and dollar amount.
Example entry. Carlos’s Paragraph 11 reads “Applicant voluntarily resigns effective 05/30/2026; applicant releases all civil and FEHA claims arising out of employment.”
Nuance. Under Labor Code §3859, only comp claims can be released on the C&R itself; civil releases require a separate civil release document.
Common mistake and consequence. Filers try to release civil claims directly on the C&R. The WCJ has no jurisdiction over those claims, and the language is unenforceable.
Misconception. People think a C&R wipes out everything. It does not — it only resolves the workers’ comp case unless a separate civil release is signed.
Three Filled-Out Examples Using Real Scenarios
Scenario 1: Maria Lopez — Accepted Specific Injury, No Medicare
| Form Section | What Maria Enters |
|---|---|
| Applicant Name | LOPEZ, MARIA ELENA |
| Employer / Carrier | FRESH MART INC. / ZURICH AMERICAN |
| ADJ Number | ADJ7654321 |
| Paragraph 1 — DOI / Body Parts | 09/15/2024; lumbar spine, left hip, sleep |
| Paragraph 3 — AWW | $700.00 |
| Paragraph 6 — Reason for Compromise | Apportionment dispute per QME Dr. Singh, 02/14/2026 |
| Paragraph 7 — Gross / Net | $55,000 gross; $38,500 net after fees and credits |
| Paragraph 8 — Medicare | Not a beneficiary; no reasonable expectation |
| Paragraph 9 — Signatures | Maria signs 05/15/2026; two neighbor witnesses |
Scenario 2: Carlos Mendoza — Cumulative Trauma With MSA
| Form Section | What Carlos Enters |
|---|---|
| Applicant Name | MENDOZA, CARLOS RUBEN |
| Employer / Carrier | WEST COAST ROOFING LLC / STATE FUND |
| ADJ Number | ADJ8881111 |
| Paragraph 1 — DOI / Body Parts | CT 01/01/2018–06/12/2024; lumbar, cervical, right shoulder, right wrist, head, psyche |
| Paragraph 3 — AWW | $1,300.00 (statutory max) |
| Paragraph 6 — Reason for Compromise | Disputed extent of PD and Almaraz/Guzman issues |
| Paragraph 7 — Gross / Net | $95,000 gross; $46,990 net after MSA, fees, lien, PD credit |
| Paragraph 8 — Medicare | SSDI applied; CMS-approved MSA $18,000 self-administered |
| Paragraph 11 — Additional Terms | Voluntary resignation effective 05/30/2026 |
Scenario 3: Janet Park — Denied COVID Claim Wash-Out
| Form Section | What Janet Enters |
|---|---|
| Applicant Name | PARK, JANET YOUNG |
| Employer / Carrier | CENTRAL VALLEY HEALTH / SEDGWICK CMS |
| ADJ Number | ADJ9990022 |
| Paragraph 1 — DOI / Body Parts | 07/22/2023; respiratory, cardiac, psyche |
| Paragraph 2 — Disputed Parts | All parts disputed; denied claim |
| Paragraph 3 — AWW | $2,100.00 (max for year of injury) |
| Paragraph 6 — Reason for Compromise | AOE/COE dispute under LC §3212.87 presumption rebuttal |
| Paragraph 7 — Gross / Net | $40,000 gross; $32,000 net after Medi-Cal lien and 15% fee |
| Paragraph 8 — Medicare | Beneficiary; CMS-approved MSA $67,400 self-administered |
How to File the Completed Form
The C&R must be filed at the WCAB District Office where the case is venued; you can find the venue in EAMS under the case header. The four filing channels are walk-through, mail, JET File, and the EAMS e-Form portal — each has different fees, processing times, and proof-of-filing requirements that determine when the lump sum check is mailed.
- Walk-through filing. Bring three originals plus a proposed Order Approving Compromise and Release to the District Office during walk-through hours posted on the DWC District Office page. There is no fee. A WCJ reviews the file the same day and signs the OACR if the file is in order; the conformed copy is your proof of filing.
- Mail filing. Mail the original plus two copies plus a self-addressed stamped envelope to the District Office. There is no fee. Processing typically runs 30–60 days; the conformed file-stamped copy returned in your SASE is your proof of filing.
- JET File (trading partners). Defense firms and large carriers file electronically through JET File. There is no fee; the JET File acceptance receipt is proof of filing, and processing runs 5–15 business days.
- EAMS e-Form filing. Represented and pro se filers with EAMS accounts upload through the EAMS e-Form portal. No fee; the e-Form confirmation number is proof of filing.
Payment of the lump sum is due within 25 working days of service of the OACR under Labor Code §5800; late payment triggers a self-imposed 10% penalty. Keep the conformed C&R, the OACR, and the carrier’s check stub together for your tax records and any future Medicare audit.
What Happens After You File
After filing, a workers’ compensation administrative law judge reviews the C&R for adequacy under Labor Code §5001. The judge looks at the body parts, the AWW, the medical reports, the lien situation, and the Medicare disclosures. If everything matches and the settlement is fair, the judge signs the Order Approving Compromise and Release.
If the judge has concerns, you receive a Notice of Intention to Disapprove with 20 days to fix the issue. Common fixes include adding a missing body part, attaching a missing medical report, clarifying the §4906(h) declaration, or providing CMS approval. Once fixed, the judge signs the OACR; if not fixed, the C&R is disapproved and the case stays open.
After the OACR is served, the carrier has 25 working days to mail the lump sum under Labor Code §5800; any party can file a Petition for Reconsideration within 20 days under Labor Code §5903 if they believe the order was issued in error. After the reconsideration window closes, the order is final under Labor Code §5908 and can only be reopened for fraud, mutual mistake, or new evidence under Labor Code §5803.
Mistakes to Avoid When Filling Out the Form
- Listing only the “main” body part. Leaves psyche, sleep, and GI as live claims the worker cannot enforce.
- Using net wages instead of gross AWW. Understates the PD rate and triggers a Notice of Intention to Disapprove.
- Forgetting PD advances credit. Double-counts payments and lets the carrier claim the difference back.
- Skipping the Medicare paragraph. CMS denies future treatment, leaving the worker personally liable.
- Using a family member as witness. Voids the signature block under Labor Code §5003.
- Releasing civil claims on the C&R itself. WCAB has no civil jurisdiction; language is unenforceable.
- Leaving Paragraph 6 vague. Triggers a request for supplemental statement of reason.
- Filing the wrong revision of the form. EAMS rejects pre-11/2008 versions for OCR errors.
- Omitting lien claimants in Paragraph 12. Liens survive the C&R and chase the worker personally.
- Forgetting the §4906(h) declaration. Attorney fee is denied until disclosure is filed.
- Using blue or fading ink, or scaling the print. OCR boxes shift and EAMS cannot index the form.
- Settling before the QME or AME report is final. Loses leverage and produces an inadequate settlement the WCJ may reject.
Do’s and Don’ts
- Do download the form fresh from DWC forms every time, because old saves may be the wrong revision.
- Do list every body part, including compensable consequences, to make the release truly final.
- Do attach the QME or AME report so the WCJ can confirm adequacy at a glance.
- Do secure CMS approval for any MSA over the $25,000/$250,000 thresholds before filing.
- Do keep the conformed copy and the OACR together for life — Medicare may audit decades later.
- Do confirm the carrier’s name on the current 30-day demand letter, because TPAs often change.
- Don’t sign in front of family members or attorneys, because the witness block becomes void.
- Don’t scale or shrink the PDF when printing, because the OCR squares move and EAMS rejects.
- Don’t leave any paragraph blank — write “None” or “Not applicable” so the judge knows it was considered.
- Don’t rely on verbal promises about future medical; if it’s not in the four corners of the form, it does not exist.
- Don’t sign before reading the Acknowledgment of Release on page 8, because it confirms you understand finality.
- Don’t release future medical without an MSA if you’re a Medicare beneficiary, because CMS will deny treatment.
Pros and Cons of Filing on Your Own vs. With Help
| Filing Pro Se | Filing With an Attorney |
|---|---|
| No 15% attorney fee deduction (more cash in pocket) | Higher gross settlements typically offset the 15% fee |
| Full control over timing and terms | Attorney handles QME, AME, and MSA negotiation |
| Direct relationship with carrier | Carrier takes case more seriously when represented |
| No conflicting strategy | Attorney spots compensable consequences pro se filers miss |
| Faster if the case is small and clean | Faster if the case is complex (CT, denied, Medicare) |
- Pro of pro se: You keep the entire net check; on a $20,000 settlement that is $3,000 you don’t pay out.
- Pro of pro se: You avoid attorney-client coordination delays at walk-through.
- Pro of pro se: Simple, accepted specific-injury cases with a clear QME often don’t need counsel.
- Pro of representation: Attorneys catch missing body parts that would otherwise stay open against you.
- Pro of representation: Attorneys negotiate MSAs and lien reductions that more than cover their fee.
- Con of pro se: No leverage in apportionment fights under Labor Code §4663.
- Con of pro se: You bear the full cost of any MSA mistake personally.
- Con of representation: 15% off the top reduces the immediate net.
- Con of representation: Attorneys may push toward C&R when a Stip with future medical fits better.
- Con of representation: Coordinating signatures and walk-throughs can add weeks to closing.
FAQs
Can I reopen a Compromise and Release after the WCJ approves it?
No. A C&R is final once the 20-day reconsideration window under Labor Code §5903 closes; reopening requires fraud, mutual mistake, or newly discovered evidence under §5803.
Do I have to list every body part in Paragraph 1, even minor ones?
Yes. Every body part — including psyche, sleep, and GI compensable consequences — must be listed, or it remains an open claim the carrier is not bound to cover.
Is “general body” enough for the body-parts paragraph?
No. WCJs reject vague entries; you must use specific anatomical terms matching the QME or AME report.
Do I write my AWW as gross or net wages in Paragraph 3?
Yes — gross. Always enter the gross average weekly wage; net wages understate PD and may invalidate the settlement.
Can my spouse sign as one of the two witnesses?
No. Labor Code §5003 requires disinterested witnesses; a spouse, child, attorney, or party is not disinterested.
Do I need a Medicare Set-Aside if I’m not on Medicare yet?
Yes, sometimes. If you have a “reasonable expectation” of Medicare within 30 months and the settlement exceeds $250,000, an MSA is required to protect Medicare’s interests.
Is the attorney fee always 15%?
No. 15% is the WCAB’s presumptive maximum; lower fees are common, and higher fees require a Petition for Increased Attorney’s Fees with detailed justification.
Can I file the C&R electronically as a pro se applicant?
Yes. Pro se filers with an EAMS account can upload through the EAMS e-Form portal, or they can walk the original to the District Office.
Do I have to attend a hearing for the C&R to be approved?
No, usually. Most C&Rs are approved on the papers at walk-through or by mail; only complex or contested settlements get set for an adequacy hearing.
When does the carrier have to pay the lump sum?
Yes — within 25 working days of service of the OACR under Labor Code §5800, or a 10% self-imposed penalty applies.
Can I leave Paragraph 12 blank if I don’t know about any liens?
No. Write “None known” or list every lien you have notice of, because unresolved liens can stop approval and chase you personally after settlement.
Does signing a C&R waive my right to sue my employer in civil court?
No, not automatically. A C&R only resolves the workers’ compensation case; civil claims (FEHA, wrongful termination) require a separate civil release.
Can I settle only future medical and keep my PD payments going?
No. A C&R closes the entire claim; if you want to keep PD payments and settle medical only, you need a different structure, often Stipulations with a separate medical buy-out.
What revision date should appear on my form?
Yes — the official revision is (Rev. 11/2008) per 8 CCR §10205.2; any older revision will be rejected by EAMS.
Related reading
- How to Fill Out California WCAB Declaration of Readiness to Proceed + FAQs
- How to Fill Out California WCAB Permanent and Stationary Report + FAQs
- How to Fill Out California WCAB Petition to Terminate Liability + FAQs
- How to Fill Out California WCAB Stipulation with Request for Award + FAQs
- How to Fill Out California WCAB DWC-AD 1 (w/Examples) + FAQs
- How to Fill Out California WCAB DWC-AD 9785 (w/Examples) + FAQs