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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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How to fill out 10139 workers compensation claim

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How to fill out 10139 workers compensation claim

01
To fill out the 10139 workers compensation claim, follow these steps:
02
Obtain the necessary claim form from your employer or insurance company.
03
Provide your personal information, such as your name, contact information, and social security number.
04
Fill in the details of your employer, including their business name, address, and contact information.
05
Describe the injury or illness that occurred at work in detail. Include the date, time, and location of the incident.
06
Provide information about the medical treatment you have received for the injury or illness.
07
Include any additional documents or evidence that support your claim, such as medical reports or witness statements.
08
Sign and date the claim form.
09
Keep a copy of the completed form for your records.
10
Submit the filled-out form to your employer or insurance company as instructed.

Who needs 10139 workers compensation claim?

01
Any worker who has experienced an injury or illness while performing job duties needs to fill out the 10139 workers compensation claim. This claim is necessary to seek compensation for medical expenses, lost wages, and other benefits provided under workers' compensation insurance. It is applicable to employees in various industries and occupations, including but not limited to construction, healthcare, manufacturing, retail, and office work.
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10139 workers compensation claim is a form filed by an employee who has been injured on the job and is seeking benefits to cover medical expenses and lost wages.
Any employee who has been injured on the job and is seeking workers compensation benefits is required to file a 10139 claim.
To fill out a 10139 workers compensation claim, the employee must provide details of the injury, how it occurred, and any medical treatment received.
The purpose of 10139 workers compensation claim is to provide injured employees with benefits to cover medical treatment and lost wages resulting from a work-related injury.
Information reported on a 10139 workers compensation claim may include details of the injury, medical treatment received, and any time missed from work.
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