The verification form is a one-page declaration that the petitioner signs to verify a Petition Appealing Administrative Director’s IMR Determination. It is published by the California Division of Workers’ Compensation (DWC). In it, the petitioner states that they read the petition, certifies that its contents are true of their own knowledge (except matters stated on information and belief) and declares this under penalty of perjury. On this page you can fill out the verification form online on FillingPDF and download or print the completed PDF. The original PDF is published by the DWC at dir.ca.gov.
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What is Verification Form for IMR Petition Appeal – California DWC?
The Verification form is the California Division of Workers’ Compensation (DWC) declaration in which the petitioner certifies that the contents of a Petition Appealing Administrative Director’s IMR Determination are true and correct, under penalty of perjury.
The text is short and fixed. The signer states that they are the petitioner in the action, that they have read the foregoing petition and know its contents, and that the contents are true of their own knowledge. The one exception is for matters stated upon information and belief, which the signer believes to be true. The signer then declares under penalty of perjury that the foregoing is true and correct.
The form has blanks for the date and city of execution, the state being printed as California. It also has a signature line, a printed name, a date, and two lines at the bottom: Attorney (if any) for Petitioner and Petitioner’s Signature. It carries a PRINT CLEAR button.
The DWC lists this document with its Independent Medical Review (IMR) forms, next to the petition it supports and the Application for Independent Medical Review (DWC IMR). The verification is not the petition and not the application for review: it only confirms the petition’s contents, and it refers to that petition as the “foregoing” document. No form number or revision date is printed on it.
Who needs to file Verification Form for IMR Petition Appeal – California DWC?
The petitioner who files a Petition Appealing Administrative Director’s IMR Determination uses this form. The text is written in the first person: the signer says “I, the undersigned, am the petitioner in the above-entitled action.” It is therefore completed for the petitioner and signed by the petitioner.
The form has a line for the Attorney (if any) for Petitioner, next to the line for the Petitioner’s Signature. This shows that a petitioner may have an attorney, but the form does not say that an attorney can sign the verification in the petitioner’s place. If you are unsure who should sign, ask the DWC or your attorney before signing a declaration under penalty of perjury.
The form is not for other IMR paperwork. The DWC’s forms page lists separate documents for the Application for Independent Medical Review (DWC IMR), the independent medical review application (DWC 9768.10) and the Authorized Representative Designation for Independent Medical Review. Use this verification only with the petition it names.
When to file Verification Form for IMR Petition Appeal – California DWC
You complete the verification when you prepare the Petition Appealing Administrative Director’s IMR Determination, because the declaration says you have read the “foregoing” petition. Read the finished petition first, then sign. The form prints no separate due date, so any deadline that applies is the one for the petition itself, which this form does not state. The date of signing is entered twice, once after “Executed on” with the city, and once on the Date line.
How to fill out Verification Form for IMR Petition Appeal – California DWC
Read the petition first
Read the whole Petition Appealing Administrative Director’s IMR Determination. The verification says you have read it and know its contents.
Enter the date of execution
After Executed on, enter the date you sign the form.
Enter the city
On the blank before “, California,” write the city where you sign the form.
Sign and print your name
Sign on the Signature line and write your name on the Print Name line. Print clearly; the form is marked PRINT CLEAR.
Date the signature
Enter the date on the Date line below your printed name.
Complete the bottom signature lines
Use the line for the Petitioner’s Signature. If you have an attorney, the line for the Attorney (if any) for Petitioner is next to it.
Review and download the completed PDF
Check that the date, city, name and signature are complete. Then download or print the completed PDF from FillingPDF and send it with the petition.
How to submit Verification Form for IMR Petition Appeal – California DWC
The form does not name its own mailing address, portal or office. The text treats it as a companion to the petition (“the foregoing Petition”), so it goes with the petition through whatever channel applies to the petition. Check the DWC’s Independent Medical Review forms on its Forms page at https://www.dir.ca.gov/dwc/forms.html, or write to [email protected], which the page gives for questions. Sign the verification yourself before it is submitted. FillingPDF lets you fill out and download the PDF; submission follows the agency’s channels.
Common mistakes to avoid
- Signing before you have read the Petition Appealing Administrative Director’s IMR Determination; the declaration states that you read it and know its contents.
- Leaving the Executed on date or the city blank; the form asks for both before California.
- Submitting the form unsigned, with no signature on the Signature line or the Petitioner’s Signature line.
- Skipping the Print Name line or writing it so it cannot be read; the form is marked PRINT CLEAR.
- Using this verification for a document other than the Petition Appealing Administrative Director’s IMR Determination; the text refers to that petition only.
- Signing as petitioner when you are not the petitioner; the declaration begins “I, the undersigned, am the petitioner.”
- Stating as personal knowledge a matter you only believe to be true; the form separates your own knowledge from information and belief.
Frequently asked questions
What is the verification form for an IMR petition?
It is a short declaration, published by the California Division of Workers’ Compensation, in which the petitioner certifies that a Petition Appealing Administrative Director’s IMR Determination is true and correct. The petitioner signs it under penalty of perjury.
Who signs the verification form?
The petitioner signs. The declaration begins “I, the undersigned, am the petitioner,” and the form has a Petitioner’s Signature line. It also has a line for an attorney, if any, but it does not say that an attorney may sign in the petitioner’s place.
What does signing under penalty of perjury mean on this form?
By signing, you declare that the foregoing is true and correct. You certify the petition’s contents are true of your own knowledge, except for matters stated on information and belief, which you believe to be true.
Can I fill out the verification form online?
Yes. You can fill out the verification form online on FillingPDF and download or print the completed PDF. FillingPDF is an independent service and does not submit the form for you; it goes to the agency with your petition through the agency’s channels.
Where do I send the verification form?
The form prints no address or portal. It refers to the “foregoing Petition,” so it goes with the petition. The DWC Forms page at https://www.dir.ca.gov/dwc/forms.html lists the Independent Medical Review forms, and questions can go to [email protected].
Is there a deadline for the verification form?
The form prints no due date of its own. Because it verifies the petition, you complete it with the Petition Appealing Administrative Director’s IMR Determination. Ask the DWC for the deadline that applies to the petition.
What is the difference between the verification and the Application for Independent Medical Review?
The verification supports a petition that appeals the Administrative Director’s IMR determination. The Application for Independent Medical Review (DWC IMR) is a separate DWC form listed with the other Independent Medical Review forms.
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