Get the free form 113 workers compensation in california - dir ca

STATE OF CALIFORNIA DEPARTMENT OF INDUSTRIAL RELATIONS DIVISION OF WORKERS COMPENSATION MEDICAL UNIT P. O. Box 71010 Oakland, CA 94612 (510) 286-3700 or (800) 794-6900 Fax: (510) 622-3467 (date) NOTICE

How to fill out form 113 workers compensation

How to fill out form 113 workers compensation:

1. Begin by entering your personal information, such as your full name, address, and contact details.
2. Provide details about your employer, including their name, address, and contact information.
3. Indicate the date of your injury or illness and provide a detailed description of how it occurred or started.
4. Specify the body parts affected by the injury or the type of illness you are experiencing.
5. Provide information about any medical treatment you have received or are currently receiving for the injury or illness.
6. Include details about any time off work or lost wages as a result of the injury or illness.
7. Sign and date the form to certify that all the information provided is true and accurate.

Who needs form 113 workers compensation:

1. Employees who have suffered a work-related injury or illness and are seeking compensation benefits.
2. Employers who are required by law to provide workers compensation benefits and need to document the employee's injury or illness.
3. Insurance companies or third-party administrators who handle workers compensation claims and need the necessary information to process the claim efficiently.

It is important to note that the specific requirements for form 113 workers compensation may vary depending on your state or jurisdiction. Therefore, it is advisable to consult with your employer, insurance provider, or legal counsel for accurate and up-to-date instructions on filling out this form.

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What is form 113 workers compensation?

Form 113 workers compensation is a document that employers use to report details about their workers' compensation insurance coverage.

Who is required to file form 113 workers compensation?

Employers who provide workers' compensation insurance coverage to their employees are required to file form 113 workers compensation.

How to fill out form 113 workers compensation?

Form 113 workers compensation can be filled out by providing information about the employer, the insurance carrier, the policy number, effective date, and expiration date of the policy.

What is the purpose of form 113 workers compensation?

The purpose of form 113 workers compensation is to ensure that employers have the required insurance coverage to provide benefits to employees who are injured or become ill on the job.

What information must be reported on form 113 workers compensation?

Information such as employer details, insurance carrier information, policy details, effective and expiration dates of the policy must be reported on form 113 workers compensation.