CA DWC Form 10214 2008-2025 free printable template
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Reset Form STATE OF CALIFORNIA DIVISION OF WORKERS COMPENSATION WORKERS COMPENSATION APPEALS BOARD COMPROMISE AND RELEASE Case Number 1 SSN Numbers Only Venue Choice is based upon Completion of this section is required County of residence of employee Labor Code section 5501. Unless otherwise expressly stated approval of this agreement RELEASES ANY AND ALL CLAIMS OF APPLICANT S DEPENDENTS TO DEATH BENEFITS RELATING TO THE INJURY OR INJURIES COVERED BY THIS COMPROMISE AGREEMENT. The parties...
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How to fill out ca form 10214
How to fill out CA DWC Form 10214
01
Begin by downloading the CA DWC Form 10214 from the California Division of Workers' Compensation website.
02
Fill out the 'Employee Information' section, including the employee's name, address, and contact information.
03
Provide details about the employer in the 'Employer Information' section, such as the company name, address, and contact details.
04
In the 'Claim Information' section, enter the date of the injury, the nature of the injury, and any relevant claim numbers.
05
Complete the 'Medical Provider Information' section with the physician's name, address, and contact information.
06
Sign and date the form at the designated area to certify that the information provided is accurate.
07
Submit the completed form to the appropriate claims administrator or department as specified in the instructions.
Who needs CA DWC Form 10214?
01
Any employee in California who has suffered a work-related injury or illness and is filing for workers' compensation benefits needs to complete the CA DWC Form 10214.
02
Employers who are involved in the workers' compensation claim process must also complete and submit this form.
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What is CA DWC Form 10214?
CA DWC Form 10214 is a document used in California's workers' compensation system, specifically for reporting claims for workers who have sustained injuries or illnesses related to their employment.
Who is required to file CA DWC Form 10214?
Employers in California who have employees that have experienced work-related injuries or illnesses are required to file CA DWC Form 10214 with the California Division of Workers' Compensation.
How to fill out CA DWC Form 10214?
To fill out CA DWC Form 10214, employers need to provide information about the injured employee, including personal details, injury information, and any medical treatments received. It's important to follow the instructions provided with the form for accurate completion.
What is the purpose of CA DWC Form 10214?
The purpose of CA DWC Form 10214 is to formally document a workers' compensation claim and to ensure that the injured employee receives the necessary medical treatment and benefits due to their workplace injury or illness.
What information must be reported on CA DWC Form 10214?
The information that must be reported on CA DWC Form 10214 includes the employee's name, address, social security number, date of birth, details of the work injury, date of injury, employer's information, and any medical treatment received.
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