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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,

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What is workers compensation claim form?

Workers compensation claim form is a legal document that injured employees use to request benefits from their employer's insurance company to cover medical expenses and lost wages.

Who is required to file workers compensation claim form?

Employees who are injured or become ill as a result of their job are required to file a workers compensation claim form.

How to fill out workers compensation claim form?

To fill out a workers compensation claim form, employees typically need to provide information about their injury or illness, how it occurred, and any medical treatment they have received.

What is the purpose of workers compensation claim form?

The purpose of workers compensation claim form is to request benefits from the employer's insurance company to cover medical expenses and lost wages for employees who are injured or become ill as a result of their job.

What information must be reported on workers compensation claim form?

Information that must be reported on workers compensation claim form includes details about the injury or illness, how it occurred, any medical treatment received, and relevant employment information.

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