Get the Free DWC Ca form 10214 (d) STATE OF CAL - FindForms.com
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APPLICATION FOR s75.00 WIDOW BENEFIT×When completed, email to Pearson mckeancountypa.org or fax to 8148873101. Of sending by mail: Zachariah J. Pearson 500 W. Main St. Southport, PA L6749 Full name
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How to fill out dwc ca form 10214
How to fill out dwc ca form 10214
01
To fill out DWC CA form 10214, follow these steps:
02
Start by entering the date of injury in the specified field.
03
Provide the employee's name, address, and phone number.
04
Fill in the employer's name, address, and phone number.
05
Indicate the employee's occupation at the time of injury.
06
Specify the date of hire and the date the employee returned to work, if applicable.
07
Describe in detail the nature of the injury or illness.
08
Provide information on the specific body parts affected by the injury or illness.
09
Include any relevant medical treatment received by the employee.
10
Indicate whether the employee was hospitalized as a result of the injury or illness.
11
Enter the name, address, and phone number of the treating physician.
12
Sign and date the form.
Who needs dwc ca form 10214?
01
DWC CA form 10214 is required for all persons who have suffered a work-related injury or illness in California.
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What is dwc ca form 10214?
DWC CA Form 10214 is a form used for reporting workplace injuries and illnesses in the state of California.
Who is required to file dwc ca form 10214?
Employers in California are required to file DWC CA Form 10214 if there are any work-related injuries or illnesses within their organization.
How to fill out dwc ca form 10214?
DWC CA Form 10214 can be filled out online on the Division of Workers' Compensation (DWC) website or manually by completing all the required fields with accurate information.
What is the purpose of dwc ca form 10214?
The purpose of DWC CA Form 10214 is to track and report workplace injuries and illnesses to ensure that employees receive proper medical treatment and benefits.
What information must be reported on dwc ca form 10214?
Information that must be reported on DWC CA Form 10214 includes details about the injured employee, the nature of the injury or illness, and the circumstances surrounding the incident.
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