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Note: This coversheet is to be used exclusively for the submission of medical documentation for unauthorized emergent services. TDI Form NumberDescriptionFile FormatLanguageDWC003Employer's wage statement. Rev.How to complete a document cover sheet. Forms filed with your local Workers' Compensation Appeals Board (WCAB) office need a "document cover sheet. Notice of Occupational Disease and Claim for Compensation. Employer Notice of No Coverage or Termination of Coverage Rev. 1 Cover Sheet - Rebuttal of Application For Board Review. The form is required to be completed fully and with care. The Contractor should list their name, address, business and insurance information. Notice of Occupational Disease and Claim for Compensation.