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10139. Workers Compensation Claim Form (DWC 1) and Notice of Potential Eligibility. Note: Authority cited: Sections 133 5307.3 and 5401, Labor Code. Reference: Sections 132(a), 139.48, 139.6, 4600,

How to fill out 10139 workers compensation claim

How to fill out 10139 workers compensation claim

1. Here is a step-by-step guide on how to fill out the 10139 workers compensation claim:
2. Obtain the 10139 workers compensation claim form from your employer or the relevant insurance company.
3. Read the instructions on the form carefully to understand the information and documentation required.
4. Provide your personal information, including your name, address, contact details, and Social Security number.
5. Fill in your employer's information, such as the company name, address, and contact details.
6. Describe the details of your injury or illness, including the date, time, and location of the incident.
7. Explain the circumstances surrounding the incident and how it relates to your work.
8. Attach any supporting documents, such as medical records, witness statements, or accident reports.
9. Provide any other relevant information requested in the form.
10. Review the completed form to ensure all the information is accurate and complete.
11. Sign and date the form.
12. Submit the filled-out form to your employer or the insurance company as instructed.
13. Keep a copy of the completed form and any supporting documents for your records.

Who needs 10139 workers compensation claim?

1. The 10139 workers compensation claim is needed by employees who have sustained work-related injuries or illnesses.
2. This claim is typically used to request compensation and benefits for medical expenses, lost wages, and rehabilitation services.
3. Workers who believe their injuries or illnesses are directly related to their work should file a 10139 workers compensation claim to seek the necessary support and financial assistance.

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