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Get the free California Workers Compensation Claim Process

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State of California Please complete in triplicate (type if possible) Mail two copies to: EMPLOYER\'S REPORT OF Preferred Employers Insurance OCCUPATIONAL INJURY OR ILLNESS Fax: 6196883913 Email: firstreport@peiwc.com
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How to fill out california workers compensation claim

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How to fill out california workers compensation claim

01
Obtain the California Workers' Compensation Claim Form (DWC 1) from your employer or download it online.
02
Fill out the employee information section with your name, address, and contact details.
03
Provide information about your employer, including the company name, address, and contact number.
04
Describe the nature of your injury or illness, including how and when it happened.
05
Indicate whether you have received medical treatment and provide details of the healthcare provider.
06
Sign and date the claim form to confirm that the information is accurate and complete.
07
Submit the completed claim form to your employer as soon as possible, ideally within 30 days of the incident.

Who needs california workers compensation claim?

01
Anyone who suffers a work-related injury or illness while performing duties for their employer.
02
Employees in California who are unable to work due to their work-related condition.
03
Individuals seeking medical treatment or financial support due to workplace injuries.
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A California workers compensation claim is a formal request for benefits filed by an employee who has sustained a work-related injury or illness. It seeks compensation for medical expenses, lost wages, and other related costs.
Any employee who suffers a work-related injury or illness while employed in California is required to file a California workers compensation claim to receive the appropriate benefits.
To fill out a California workers compensation claim, you need to complete a claim form (DWC 1) provided by your employer or the insurance company, providing detailed information about the injury, the circumstances surrounding it, and any medical treatment received.
The purpose of a California workers compensation claim is to provide financial assistance and medical care to employees who are injured or become ill due to their job, ensuring they receive the necessary support during their recovery.
The information that must be reported on a California workers compensation claim includes personal details of the employee, details of the injury or illness, date and place of the incident, and medical treatment received or needed.
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