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Placer County s Workers Compensation administrator is Intercare Holdings Insurance Services Inc. Phone 800-771-5454. ACKNOWLEDGEMENT OF RECEIPT Receipt of Employee Claim Form DWC-1 Employer Representative Instructions Use this form to document each time you provide a DWC-1 to an injured worker. Provide injured worker with current Approved WC doctor list. Injured Worker Sign and return this form to the employer representative when a DWC-1 is provided to you. Employer Human Resources-Workers...
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01
Gather all necessary information about the injured worker, such as their full name, date of birth, and contact details.
02
Collect information about the injury, including the date and time it occurred, the location, and the cause.
03
Fill out any medical details related to the injury, such as the nature of the injury, any treatments or surgeries performed, and any medications prescribed.
04
Include information about the employer or company the injured worker is associated with, such as their name, address, and contact information.
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Provide any additional documentation or evidence related to the injury, such as witness statements or accident reports.
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Review the filled-out injured worker form for accuracy and completeness before submission.
Who needs the injured worker is?
01
Employers who have employees that have been injured on the job need the injured worker form.
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What is the injured worker is?
The injured worker is the employee who has suffered an injury or illness while on the job.
Who is required to file the injured worker is?
The employer is required to file the injured worker report.
How to fill out the injured worker is?
The injured worker report can be filled out online or by submitting a paper form to the appropriate state agency.
What is the purpose of the injured worker is?
The purpose of the injured worker report is to document and track work-related injuries and illnesses for statistical and compensation purposes.
What information must be reported on the injured worker is?
The injured worker report must include details about the employee, the injury or illness, and the circumstances surrounding the incident.
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