Get the free dwc ad form 1013357 - dir ca
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Reset Formulate OF CALIFORNIA
DIVISION OF WORKERS' COMPENSATION
WORKERS' COMPENSATION APPEALS BOARD
THIRD PARTY
COMPROMISE AND RELEASE Case Number 1Case Number 4Case Number 2Case Number 5Case Number
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How to fill out dwc ad form 1013357
How to fill out DWC AD Form 1013357:
01
Start by writing the current date in the designated section of the form.
02
Provide the name of the injured worker in the next field.
03
Fill in the worker's social security number, date of birth, and address.
04
Specify the date and time of the injury or illness and describe how it occurred.
05
Indicate the body parts affected by the injury or illness.
06
Include details of any medical treatment or visits related to the incident.
07
If the worker has missed work due to the injury or illness, record the dates and the number of days absent.
08
Provide the worker's average weekly wage before the injury or illness.
09
If the worker returned to work, indicate the date of return.
10
Sign and date the form.
11
Employers or their insurance carriers should also complete their sections of the form, providing information about the policyholder, employer, and insurance carrier.
Who needs DWC AD Form 1013357?
01
Employers who have workers' compensation insurance policies.
02
Insurance carriers who provide workers' compensation coverage.
03
Injured workers or their representatives who need to report a work-related injury or illness.
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What is dwc ad form 1013357?
DWC AD Form 1013357 is a form used for reporting workplace injuries and illnesses in the state of California.
Who is required to file dwc ad form 1013357?
Employers in the state of California are required to file DWC AD Form 1013357 for any workplace injuries or illnesses.
How to fill out dwc ad form 1013357?
DWC AD Form 1013357 can be filled out online or in paper format. It requires information about the injured worker, the nature of the injury or illness, and details about the incident.
What is the purpose of dwc ad form 1013357?
The purpose of DWC AD Form 1013357 is to provide a standardized way for employers to report workplace injuries and illnesses, ensuring proper documentation and tracking.
What information must be reported on dwc ad form 1013357?
DWC AD Form 1013357 requires information such as the injured worker's personal details, the employer's information, the incident details, medical treatment information, and any witnesses or witnesses' statements.
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