Get the free DWC Ca form 10214 (c) ver1 9-8-08 - State of California - s3 documentcloud
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Sep 8, 2008 ... COMPROMISE AND RELEASE ... DWC-CA form 10214 (c) (Rev. ... out of and in the course of employment at the locations and during the dates listed below: ... Upon approval of this compromise
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How to fill out dwc ca form 10214
How to fill out DWC CA form 10214:
01
Start by downloading the form from the official website of the California Division of Workers' Compensation (DWC).
02
Fill in the first section by providing your full name, address, and contact information.
03
In the second section, enter the name of your employer and their address.
04
Indicate the date of your injury or illness in the third section.
05
Provide details of your job title and description at the time of the incident in the fourth section.
06
Fill in the fifth section by describing how the injury or illness occurred and provide a detailed account of the circumstances.
07
If you received medical treatment, list the healthcare providers' names, addresses, and the dates of the treatment in the sixth section.
08
In the seventh section, indicate whether you have filed any other workers' compensation claims related to this injury or illness.
09
Sign and date the form in the designated area.
10
Keep a copy of the completed form for your records.
Who needs DWC CA form 10214:
01
Employees who have suffered a work-related injury or illness in the state of California need DWC CA form 10214.
02
Employers are required to provide this form to their employees if they experienced a work-related injury or illness.
03
Healthcare providers treating workers' compensation patients may also need to use this form for reporting purposes.
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What is dwc ca form 10214?
dwc ca form 10214 is a form used for reporting workplace injuries and illnesses in the state of California.
Who is required to file dwc ca form 10214?
Employers in California are required to file dwc ca form 10214 for any workplace injuries or illnesses.
How to fill out dwc ca form 10214?
dwc ca form 10214 can be filled out online on the Division of Workers' Compensation (DWC) website or submitted by mail.
What is the purpose of dwc ca form 10214?
The purpose of dwc ca form 10214 is to track and report workplace injuries and illnesses in order to ensure worker safety and compliance with regulations.
What information must be reported on dwc ca form 10214?
Information reported on dwc ca form 10214 includes details of the injury or illness, treatment received, and any lost work time.
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