Can this form be signed electronically?

Yes. Electronic signatures are generally enforceable under the federal ESIGN Act and state electronic signature laws provided the signer demonstrates intent, consent, attribution, and the record is retained in reproducible form.

What authentication strength is recommended?

Use two-factor methods (email plus SMS code or SSO) for attribution and auditability. Strong authentication reduces questions about signer identity and supports compliance with 21 CFR Part 11 or HIPAA when PHI is involved.

Where do I submit the completed form?

Submit to the California DWC office or secure portal specified on the form. If you are unsure, use the regulator contact listed on official DWC guidance to confirm the correct mailbox or intake channel.

What supporting documents should accompany the form?

Attach copies of business registration, claims administration agreement, regulatory license, and a delegated authority letter when applicable. Missing attachments are a frequent cause of processing delays.

How do I correct an error after filing?

Submit an amended form or corrective submission following DWC instructions; include a cover note explaining the correction. Retain all versions and an audit trail showing who made the change and when.

Who is authorized to sign this form?

An officer, authorized agent, or registered representative of the administrator should sign. Authority should be documented; some filings require a notarized signature or corporate resolution for verification.

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California Department of Workers' Compensation Claims Administrator Information

California Department of Workers' Compensation Claims Administrator Information

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State of California

Division of Workers' Compensation

REQUEST FOR CONCLUSION OF REHABILITATION BENEFITS

INSTRUCTIONS:

This form must be used by the employer/insurer to request the Rehabilitation Unit to determine when vocational rehabilitation benefits are concluded. This form is required on all cases in which vocational rehabilitation benefits commenced. This request must be sent to the applicable Unit office. If a Rehabilitation Unit case number has not been assigned, attach a completed Case Initiation Document RU-101. This form should not be used for interruptions of benefits.

REHABILITATION UNIT USE ONLY

EMPLOYEE NAME:

RU CASE #:

EMPLOYEE ADDRESS:

REHABILITATION UNIT ADDRESS:

CITY, STATE, ZIP:

The Employer/Insurer requests Rehabilitation Unit approval of conclusion of vocational rehabilitation services because:

the qualified injured worker completed a vocational rehabilitation plan.

the employee is not a qualified injured worker or the employee failed to cooperate in the provision of vocational rehabilitation services to determine the employee's eligibility as a qualified injured worker.

the qualified injured worker unreasonably failed to complete an approved vocational rehabilitation plan.

the employee declined, on the prescribed form, to accept the provision of vocational rehabilitation services.

the employee failed to request timely reinstatement of vocational rehabilitation services.

none of the above reasons apply and all necessary and reasonable vocational rehabilitation services have been provided.

The basis for this request is substantiated in the attached reports and is summarized as follows:

NOTICE TO EMPLOYEE

If you object to this request, you (or your attorney, if you are represented) must submit your written objections and the reasons for them to the Rehabilitation Unit within 20 days of the date of this request. The objection should be made on the Request for Dispute Resolution Form RU-103 and a copy must be sent to the employer/insurer.

Within specified time limits and subject to certain criteria, you may request reinstatement of vocational rehabilitation benefits. Requests must be in writing, accompanied by supporting facts and submitted to the Rehabilitation Unit within one year of either a finding of permanent disability or approval of a compromise and release by the Workers' Compensation Appeals Board, or within 5 years from the date of your injury. The Rehabilitation Unit will determine if the vocational rehabilitation services previously provided were sufficient or if you are entitled to additional services.

SUMMARY OF VOCATIONAL REHABILITATION BENEFITS PROVIDED

Date Rehab Services Commenced-

Rehab Plan Type-

Rehab Plan Goal-

Date Rehab Services Completed:

Return to Work: YES NO

Date-

Employee's New Job Title-

Wages: $ per

1. The employee has been paid $ in temporary disability indemnity benefits at the rate of $ per week,

beginning and ending for the injury occurring on

2. Vocational rehabilitation services provided to the employee include: (check where applicable)

Job Analysis

Vocational Evaluation

Vocational Testing

Situational Assessments

Counseling

Labor Market Survey

Financial Analysis

Training: Number of Weeks-

Placement Services: Number of Weeks-

Other (Specify)-

COPIES OF THIS NOTICE HAVE BEEN SENT TO:

SUBMITTED BY (Name):

SIGNATURE:

ADDRESS:

CITY, STATE, ZIP:

PHONE NUMBER:

DATE:

State of California

DWC Form RB-105 (pre 1/1/90)

Rehabilitation Unit

California Division of Workers' Compensation

Form RB-105

REQUEST FOR CONCLUSION OF REHABILITATION BENEFITS

Purpose:

To request the Rehabilitation Unit's approval of conclusion of rehabilitation services for injuries before 1/1/90. For injuries on or after 1/1/90, use the Notice of Termination of Vocational Rehabilitation Services Form RU-105.

Submitted by:

Claims administrator.

When submitted:

Within ten (10) days of the circumstances as described on the form.

Where submitted:

To the applicable Rehabilitation Unit district office.

Form completion:

Please note this form will be returned or the request denied if

No rehabilitation case number has been assigned nor was the RU-101 Case Initiation Document attached.
The box was not checked for the reason of the request.
The request lacks substantiation as required.
Copies have not been sent to the employee and his/her representative, if represented.
The copy of service section is incomplete.

Accompanying documents:

Relevant medical and vocational reports.

Rehabilitation Unit action:

When the employee objects to the RB-105, the Rehabilitation Unit will hold a conference or otherwise obtain the reason for objection and issue its decision. If the employee objects, a RU-103 Request for Dispute Resolution must be filed. Check the box "the requesting party objects to the request for termination or conclusion of vocational rehabilitation benefits" and provide the reasons for the objection.

Copy:

All parties.

Overview of the Claims Administrator Information form

The California Department of Workers' Compensation Claims Administrator Information is a standardized submission used to report identifying and contact information for a claims administrator handling workers' compensation matters in California. It collects administrator name, address, license or registration numbers, designated contact person, business hours, and electronic filing or representative details so regulators, employers, and claimant representatives can locate and verify the entity managing claims.

Why accurate administrator information matters

Providing complete, correct claims administrator information ensures regulatory compliance, speeds claim routing, and preserves insured parties' rights. Accurate entries reduce follow-up requests and support timely communications between the DWC, employers, insurers, and claimants.

Who completes and relies on this form

Accurate entries make administration transparent and reduce disputes over who is authorized to act on a claim.

Self-insured employers and their third-party administrators who manage workers' compensation claims for employees.
Insurance carriers and delegated claims administrators contracted to process claims on behalf of insurers.
Regulatory staff, employer representatives, and claimant counsel seeking official contact and licensing details.

Core elements found in a professional submission

A complete Claims Administrator Information submission groups identity, contact, licensing, operational, and electronic details so reviewers can quickly verify authority and reach appropriate staff.

Administrator Name

Full legal business name and any DBA designations as registered with the California Department of Insurance or other licensing body; use exact corporate punctuation and capitalization.

Physical Address

Street address including city, state, and ZIP code. Provide a physical location rather than a P.O. box when the form requests a principal place of business for service and inspection.

Mailing and Billing

Separate mailing or billing addresses and a preferred method for correspondence; note differences to avoid misdirected notices or late payments.

Designated Contact

Name, job title, phone number, and business email for the person responsible for claim coordination and regulatory inquiries.

Licenses and IDs

Regulatory license numbers, claims administrator registration ID, or insurance carrier NAIC number as applicable; include issuing state and expiration dates if required.

E-Filing and Systems

Electronic submission capability, secure mailbox identifiers, and preferred digital formats for reports and records to facilitate automated exchanges.

Required data fields at a glance

Legal name: Exact as registered

DBA: If applicable

Physical address: Street, city, state, ZIP

Designated contact: Name and phone

Regulatory ID: License or registration number

Email and e-file ID: Business email and system ID

Step-by-step: filling and submitting the form

Complete the form in sequence to ensure all cross-referenced fields are accurate and systems recognize the administrator for filings and service.

01

Gather documents: Collect license, corporate formation, and contact verification documents.
02

Enter identifying data: Populate legal name, DBA, and physical address carefully.
03

Provide contact details: Add designated contact, phone, and email; confirm deliverability.
04

Sign and submit: Sign as authorized representative and follow filing instructions.

Configure online submission and routing

Set up digital routing and verification fields before uploading documents to reduce manual intervention and accelerate acceptance.

Field	Configuration
Document format	PDF/A preferred; preserve original formatting and attachments
Signer authentication	Use email plus SMS code or organization SSO for attribution
Audit trail options	Enable IP, timestamp, and action logs for each signer
Notification routing	Set primary and backup email recipients for regulatory notices

Where to send and how routing works

Understand destination and routing so your submission reaches the correct DWC unit and designated contacts without delay.

State submission: Send to the DWC address or secure portal indicated on the form.
Employer notices: Copy the employer or insurer contact specified in the file.
Claimant communications: Ensure claimant representative addresses are included when required.
Electronic mailbox: Use the DWC e-file ID if the regulator supports secure electronic exchange.

Digital signing and eSubmission essentials

Verify that your e-signature provider supports ESIGN/UETA and retains an audit trail to meet evidentiary requirements for regulatory review.

File formats: PDF, DOCX accepted
Authentication: Email + SMS or SSO
Audit records: IP and timestamps

Key timelines and processing expectations

Be aware of internal and statutory timelines for registration updates, change notifications, and responses to DWC inquiries to avoid penalties or administrative delays.

Initial registration update:

Submit upon change of administrator or contact; no fixed statutory deadline

Regulatory response window:

Respond to DWC requests as directed in notice, typically within 30 days

Document retention notice:

Keep submitted records until closure plus retention period

Claim correspondence:

Acknowledge claim assignment within business hours stated

Appeal or protest timelines:

Follow the DWC-specified deadlines in any notice or decision

Typical processing milestones after submission

A typical submission follows a sequence from intake to verification to activation; understanding each stage clarifies your responsibilities and expected timing.

01

Intake and validation

DWC checks completeness and flag missing items for correction.

02

Primary review

Assigned reviewer verifies license and contact information accuracy.

03

Approval or request

DWC issues acceptance or requests supplemental documentation.

04

Activation and notice

Approved administrator is listed and notices sent to stakeholders.

Common preparation errors to avoid

Using inconsistent business names across documents which prevents automated verification and triggers manual review, causing delays.
Omitting contacting details or providing inactive email addresses that prevent timely notifications and regulatory queries from being delivered.
Uploading non-searchable scanned images without readable text or incorrect file formats, which lengthens validation and acceptance time.
Failing to include regulatory IDs or entering expired license numbers, which can lead to rejection or requirement to refile.

Consequences of incorrect or incomplete filings

Operational delays: Delayed claim handling

Regulatory rejection: Form returned or refused

Fines: Possible monetary penalties

Liability exposure: Service or notice failures

Reputational harm: Stakeholder trust reduced

Audit findings: Increased oversight

Comparison: common eSignature providers for form submission

Platform choice affects authentication, HIPAA support, and per-user cost; the table below summarizes typical entry-level pricing and key capability distinctions.

	signNow	DocuSign	Adobe Sign	PandaDoc	HelloSign
Starting Price	$8/user/mo	$15/user/mo	$14/user/mo	$19/user/mo	$15/user/mo
Free Trial	7-day free trial	Free trial available	Free trial available	Free trial available	Free trial available
Bulk Send	Yes	Yes	Yes	Yes	No
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Yes	Yes	No	No
Envelope Cap	No cap	100 envelopes/user/year	Varies by plan	Varies by plan	Varies by plan

Frequently asked questions and practical answers

Answers to common questions about form completion, electronic signatures, filing destinations, and post-submission updates to minimize processing issues and regulatory follow-up.

Need help? Contact support

Can this form be signed electronically?
Yes. Electronic signatures are generally enforceable under the federal ESIGN Act and state electronic signature laws provided the signer demonstrates intent, consent, attribution, and the record is retained in reproducible form.
What authentication strength is recommended?
Use two-factor methods (email plus SMS code or SSO) for attribution and auditability. Strong authentication reduces questions about signer identity and supports compliance with 21 CFR Part 11 or HIPAA when PHI is involved.
Where do I submit the completed form?
Submit to the California DWC office or secure portal specified on the form. If you are unsure, use the regulator contact listed on official DWC guidance to confirm the correct mailbox or intake channel.
What supporting documents should accompany the form?
Attach copies of business registration, claims administration agreement, regulatory license, and a delegated authority letter when applicable. Missing attachments are a frequent cause of processing delays.
How do I correct an error after filing?
Submit an amended form or corrective submission following DWC instructions; include a cover note explaining the correction. Retain all versions and an audit trail showing who made the change and when.
Who is authorized to sign this form?
An officer, authorized agent, or registered representative of the administrator should sign. Authority should be documented; some filings require a notarized signature or corporate resolution for verification.

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