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STATE OF CALIFORNIA DIVISION OF WORKERS' COMPENSATION WORKERS' COMPENSATION APPEALS BOARD APPLICATION FOR ADJUDICATION OF CLAIM Print Form Reset Form Amended Application Case No. SSN (Numbers Only)
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How to fill out DWC WCABVER1-9-24-08 - California:

01
Start by reading the form carefully to understand its purpose and requirements.
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Provide your personal information in the designated sections, such as your full name, address, and contact information.
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Identify your employer's information, including their name, address, and contact details.
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Indicate the date and time when the injury or illness occurred, as well as the specific location where it happened.
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Describe the injury or illness in detail, mentioning the body parts affected and any symptoms or medical conditions related to it.
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If you have received medical treatment for the injury or illness, provide the name and contact information of the healthcare provider or facility.
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Explain how the injury or illness happened, providing a brief account of the circumstances leading to it.
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Mention any witnesses who can support your claim, including their names and contact information.
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Sign and date the form, certifying the accuracy and truthfulness of the information provided.

Who needs DWC WCABVER1-9-24-08 - California:

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Employees who have suffered a work-related injury or illness in the state of California.
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Employers who need to report the specific details of an employee's work-related injury or illness to the California Workers' Compensation Appeals Board.
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Healthcare providers who have treated an employee for a work-related injury or illness and need to submit the necessary information to support the employee's claim for workers' compensation benefits.
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This form, also known as the Proof of Service by Mail, is used to document the mailing of documents related to workers' compensation cases in California.
Attorneys or representatives handling workers' compensation cases in California are required to file this form.
The form must be filled out with the details of the documents being mailed, including the date of mailing, recipient's name and address, and the name of the document.
The purpose of this form is to provide proof that documents related to a workers' compensation case have been properly served to the parties involved.
The form requires details such as the date of mailing, recipient's name and address, name of the document being served, and the sender's information.
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