The compromise and release is the settlement agreement that parties to a California workers' compensation claim sign when they agree to resolve the claim for a lump sum. DWC-CA form 10214 (c) is published by the California Division of Workers' Compensation (DWC) for the Workers' Compensation Appeals Board (WCAB). It records the injuries and body parts being settled, the settlement amount, the deductions and the issues in dispute. On this page you can fill out the form online on FillingPDF and download or print the completed PDF; the form itself is published by the DWC.
Last updated
What is DWC-CA form 10214 (c)?
Form 10214 (c), Compromise and release, is the California Division of Workers' Compensation (DWC) form on which the parties to a workers' compensation claim record a compromise settlement for approval by the Workers' Compensation Appeals Board (WCAB) or a workers' compensation administrative law judge.
The form is nine pages. It identifies the case numbers, venue, employee, employer, attorneys or representatives, insurance carrier and claims administrator. Paragraph 1 states the date or dates of injury and the body parts, conditions or systems being settled, for up to five case numbers. Paragraph 6 lists agreed facts such as earnings and benefits paid, paragraph 7 sets the settlement sum and deductions, and paragraph 9 lists the disputed issues.
Under paragraph 2, once the agreement is approved and paid, the employee releases the named employer(s) and insurance carrier(s) from claims arising from the listed injuries. Paragraph 4 states that approval releases the claims of the applicant's dependents to death benefits for those injuries unless otherwise expressly stated. Paragraph 5 states that approval does not release any claim for vocational rehabilitation or supplemental job displacement benefits unless expressly ordered otherwise.
The release does not reach claims outside the workers' compensation law, or claims not subject to its exclusivity provisions, unless the form expressly says so.
Who needs to file DWC-CA form 10214 (c)?
The form is completed by the parties who are settling a California workers' compensation claim by compromise and release: the injured employee (the applicant) and the defendants, meaning the employer and its insurance carrier or claims administrator.
- The applicant signs the agreement. Paragraph 11 requires that signature to be attested by two disinterested persons or acknowledged before a notary public.
- The applicant's attorney or authorized representative, whether a law firm or attorney or a non-attorney representative, is listed on page 2 and signs as attorney for applicant.
- The defendant's attorney or authorized representative is listed on page 2 and signs as attorney for defendant.
- The employer section asks whether the employer is insured, self-insured, legally uninsured or uninsured. The carrier and claims administrator sections are completed if known and if applicable.
- An interpreter line appears in the signature block.
The form covers up to five case numbers. It has no effect on claims outside the scope of the workers' compensation law, or claims not subject to its exclusivity provisions, unless it expressly says otherwise. Paragraph 11 warns employees that settling may affect other benefits, including Social Security, Medicare and long-term disability benefits.
When to file DWC-CA form 10214 (c)
Use Form 10214 (c) when the parties have agreed to settle the claim and are ready to submit the agreement for approval. The form prints no filing deadline and no processing time.
Several dates still matter. Paragraph 7 says interest under Labor Code section 5800 is included if the sums are paid within 30 days after the date of approval. The settlement takes effect only on approval by the WCAB or a workers' compensation administrative law judge, and payment under its terms.
Paragraph 10 provides that filing the document is the filing of an application. The judge may set the matter for hearing as a regular application, and may then either approve the compromise and release or disapprove it and issue Findings and Award after hearing.
Documents you need
- Addendum to paragraph 8, only if the liens not mentioned in paragraph 7 cannot be disposed of in the space provided; the form says to attach an addendum if necessary.
- Notary acknowledgment (page 9 of the form), only if the applicant's signature is acknowledged before a notary public instead of being attested by two disinterested persons.
- Document Cover Sheet: the 3-letter office code for the place or venue of hearing on page 1 is taken from it.
How to fill out DWC-CA form 10214 (c)
Enter case numbers and SSN
At the top of page 1, enter up to five case numbers and the employee's Social Security number, numbers only.
Choose the venue basis and office code
Check the basis for venue: county of residence of the employee, county where the injury occurred, or county of principal place of business of the employee's attorney. Then select the 3-letter office code for the place of hearing from the Document Cover Sheet.
Complete employee and employer sections
Enter the employee's name and address. Mark the employer as Insured, Self-Insured, Legally Uninsured or Uninsured, and enter the employer's name and address, leaving blank spaces between words.
List both sides' representatives
On page 2, choose Law Firm/Attorney or Non Attorney Representative for the applicant and the defendant, and enter names, law firm number, firm name and address. Add the insurance carrier and claims administrator on pages 2 and 3 if known and applicable.
Complete paragraph 1 for each injury
Enter the employee's date of birth (MM/DD/YYYY) and occupation at the time of injury. For each case number, mark Specific Injury or Cumulative Injury with the MM/DD/YYYY dates, list body parts 1 to 4 and other body parts, and give the injury location.
Read paragraphs 2 to 5
These paragraphs state the release, the limit to the injuries in paragraph 1, the release of dependents' death benefits, and that vocational rehabilitation and supplemental job displacement claims are not released unless ordered otherwise. Do not attach a Sumner addendum.
State the agreed facts in paragraph 6
Enter earnings at time of injury, temporary and permanent disability indemnity paid with weekly rates and MM/DD/YYYY periods, total medical bills paid, and who pays unpaid medical expense.
Enter the settlement in paragraph 7
Enter the settlement sum, then the deductions: permanent disability advances, temporary disability overpayment, payees and the requested attorney's fee. Enter the resulting balance.
Dispose of liens in paragraph 8
Describe how liens not mentioned in paragraph 7 are to be handled, and attach an addendum if necessary.
Initial the disputed issues
In paragraph 9, both the applicant side and the defendant side initial each issue that applies, such as earnings, apportionment or permanent disability. Add any comments.
Arrange signatures and acknowledgment
Paragraph 11 requires the applicant's signature to be attested by two disinterested persons or acknowledged before a notary on page 9. Attorneys and any interpreter sign and date their lines.
Review and download the PDF
Check every required section, the dates and the signature block, then download or print the completed PDF from FillingPDF.
How to submit DWC-CA form 10214 (c)
Form 10214 (c) is filed with the Workers' Compensation Appeals Board for approval at the hearing office you select on page 1; the form prints no mailing address, portal or fee.
- Hearing office: Page 1 asks for the 3-letter office code for the place or venue of hearing, taken from the Document Cover Sheet.
- Signatures first: Before filing, the applicant's signature must be attested by two disinterested persons or acknowledged before a notary public using the acknowledgment on page 9.
- Addenda: If paragraph 8 needs an addendum for liens, attach it.
- Where to find the form: The DWC publishes it with its other forms at https://www.dir.ca.gov/dwc/forms.html. The DWC invites questions at [email protected].
Confirm the current filing method with the DWC or the WCAB before submitting. FillingPDF lets you fill out and download the PDF; submission follows the channels above.
Common mistakes to avoid
- Leaving the venue section blank. The form states that the venue choice, the 3-letter office code, and the employee and employer sections are required.
- Incorporating body parts, conditions or systems by reference to medical reports. Each injury block says this is not allowed; list them in paragraph 1.
- Initialing a disputed issue in paragraph 9 for only one side. Only issues initialed by both the applicant or representative and the defendants or representatives are included in the settlement.
- Attaching an addendum that repeats the Sumner v WCAB death-benefits language. Paragraph 4 says such an addendum is unnecessary and shall not be attached.
- Having the applicant sign without two disinterested witnesses or a notary acknowledgment. Paragraph 11 requires one or the other.
- Entering a Social Security number with dashes or spaces. The field says Numbers Only.
- Running names or numbers together in address fields. The form asks you to leave blank spaces between numbers, names or words.
- Assuming the settlement reaches body parts or dates of injury not listed in paragraph 1. Paragraph 3 limits the agreement to those listed there and explained in paragraph 9.
Frequently asked questions
What is a compromise and release in California workers' comp?
A compromise and release is an agreement that settles a workers' compensation claim for a sum of money. DWC-CA form 10214 (c) is the form used. Once the WCAB or a judge approves it and it is paid, the employee releases the employer and insurance carrier from claims arising from the listed injuries.
Does a compromise and release give up death benefits?
Yes, unless the form expressly states otherwise. Paragraph 4 says approval releases any claims of the applicant's dependents to death benefits relating to the injuries covered, and the parties consider that release when setting the sum in paragraph 7.
Does it release vocational rehabilitation or job displacement benefits?
Not automatically. Paragraph 5 says approval does not release any claim for vocational rehabilitation benefits or supplemental job displacement benefits unless the WCAB or a judge expressly orders otherwise.
Who has to witness or notarize the applicant's signature?
Paragraph 11 says the applicant's signature must be attested by two disinterested persons or acknowledged before a notary public. Page 9 of the form contains the California notary acknowledgment.
Can one form cover more than one injury?
Yes. The form has space for up to five case numbers, each with its own specific or cumulative injury dates, body parts and injury location. Paragraph 3 limits the settlement to the body parts, conditions and dates listed there.
Are medical expenses paid after the settlement is approved?
Not by the employer, unless the form says otherwise. Paragraph 6 states that, unless otherwise specified, the employer will pay no medical expenses incurred after approval of the agreement.
What happens if the judge does not simply approve it?
Under paragraph 10, filing the form counts as filing an application. The judge may set a hearing, and may then approve the compromise and release or disapprove it and issue Findings and Award after the matter is submitted.
Can I fill out the compromise and release online?
Yes. You can fill out the fillable PDF online on FillingPDF and download or print it. FillingPDF is an independent service and does not file the form with the WCAB; filing follows the channels described under how to submit.
Ready to fill out DWC-CA form 10214 (c)?
Fill out DWC-CA form 10214 (c) now