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PRINT. State of California
Department of Industrial Relations
DIVISION OF WORKERS COMPENSATION CLAIM FORM (DWC 1)
Employee: Complete the Employee section and give the form to your
employer. Keep a
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How to fill out workers compensation claim form
How to fill out workers compensation claim form
01
To fill out a workers compensation claim form, follow these steps:
02
Begin by providing your personal information, including your name, address, phone number, and social security number.
03
Next, provide details about your employer, such as the name of the company, address, and contact information.
04
Describe the date and time of the accident or injury that led to the workers compensation claim. Include any specific details about how the accident occurred.
05
Specify the type of injury or illness you have suffered as a result of the accident or exposure at your workplace.
06
Indicate the medical treatment you have received, including the names of healthcare providers, hospitals, and dates of appointments.
07
If you have already missed work as a result of the injury, provide details about the days or hours you were unable to work and the wages you have lost.
08
Attach any supporting documentation, such as medical records, receipts for expenses related to the injury, or witness statements.
09
Review and double-check all the information provided before submitting the workers compensation claim form.
10
Finally, submit the completed form to the appropriate workers compensation board or insurance provider.
Who needs workers compensation claim form?
01
Workers who have been injured or have developed an illness due to their work-related activities require a workers compensation claim form.
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What is workers compensation claim form?
The workers compensation claim form is a document that an employee files with their employer's insurance company to request benefits in case of a work-related injury or illness.
Who is required to file workers compensation claim form?
Any employee who suffers a work-related injury or illness is required to file a workers compensation claim form.
How to fill out workers compensation claim form?
To fill out a workers compensation claim form, the employee needs to provide details about the injury or illness, how it occurred, and any medical treatment received.
What is the purpose of workers compensation claim form?
The purpose of the workers compensation claim form is to ensure that employees receive benefits for work-related injuries or illnesses without having to go through a legal process.
What information must be reported on workers compensation claim form?
The worker must report details about the injury or illness, the date and time it occurred, and provide any medical documentation related to the incident.
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