Get the free DWC Form 5 - September 2009.doc
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STATE OF CALIFORNIA DEPARTMENT OF INDUSTRIAL RELATIONS DIVISION OF WORKERS COMPENSATION REQUEST FOR ACCOMMODATION BY PERSONS WITH DISABILITIES 1. Name:Telephone Number:2. Mailing Address: 3. Email
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How to fill out dwc form 5
How to fill out dwc form 5
01
Obtain a DWC Form 5 from the relevant organization or online.
02
Fill in your personal information such as name, address, and contact details.
03
Provide details of your employer including name, address, and contact information.
04
Specify the date of your injury or illness that led to the need for workers' compensation.
05
Explain the details of your injury or illness and how it occurred.
06
Sign and date the form before submitting it to the appropriate party.
Who needs dwc form 5?
01
Employees who have suffered a work-related injury or illness and are seeking workers' compensation benefits.
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What is dwc form 5?
DWC Form 5 is a report used by employers to provide information about workplace injuries and illnesses to the Division of Workers' Compensation.
Who is required to file dwc form 5?
Employers in certain industries who are subject to workers' compensation reporting requirements are required to file DWC Form 5.
How to fill out dwc form 5?
To fill out DWC Form 5, employers need to provide details about the injured employee, the nature of the injury, and the circumstances surrounding the incident.
What is the purpose of dwc form 5?
The purpose of DWC Form 5 is to collect data on workplace injuries and ensure compliance with workers' compensation regulations.
What information must be reported on dwc form 5?
Information that must be reported includes the employee's details, injury details, date of the incident, type of injury, and treatment received.
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