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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. To fill out the 10139 workers compensation claim, follow these steps:
2. Obtain the necessary forms from your employer or workers compensation board.
3. Provide your personal information, including your name, address, and contact details.
4. Fill in the details of your employer, including their business name and address.
5. Provide the date and time of the injury or illness that is the basis of the claim.
6. Describe the nature of the injury or illness and how it occurred.
7. Provide details of any medical treatment received and the healthcare provider's information.
8. Include any witness statements or evidence supporting your claim.
9. Sign and date the claim form.
10. Submit the completed form to the appropriate workers compensation office or your employer.
11. Keep a copy of the completed form for your records.

Who needs 10139 workers compensation claim?

1. Any employee who has suffered a work-related injury or illness and wishes to seek compensation needs the 10139 workers compensation claim.
2. This claim form is typically required by the workers compensation board or the employer's insurance provider to initiate the claims process and determine eligibility for benefits.
3. It is important for employees to promptly submit this claim to ensure timely processing and potential financial support during their recovery period.

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What is 10139 workers compensation claim?

A 10139 workers compensation claim is a form filed by an employee who has been injured or become ill on the job.

Who is required to file 10139 workers compensation claim?

Employees who have been injured or become ill as a result of their job are required to file a 10139 workers compensation claim.

How to fill out 10139 workers compensation claim?

To fill out a 10139 workers compensation claim, the employee needs to provide information about the injury or illness, as well as details about the incident that caused it.

What is the purpose of 10139 workers compensation claim?

The purpose of a 10139 workers compensation claim is to seek compensation for medical expenses and lost wages resulting from a work-related injury or illness.

What information must be reported on 10139 workers compensation claim?

Information that must be reported on a 10139 workers compensation claim includes details of the injury or illness, the date and location it occurred, and any witnesses.