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This form is used by employers identified as rejected risks to request consultation services from the DWC. It collects employer information, worksite details, and includes a section for the consultant\'s

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How to fill out dwc104

01

Start by downloading the DWC-104 form from the official website.

02

Fill in the 'Employee Information' section with the employee's name, address, and Social Security number.

03

Complete the 'Employer Information' section with your company's name, address, and employer identification number.

04

In the 'Claim Information' section, provide details about the nature of the claim and the date of injury.

05

Review the 'Payments' section to report any compensation or benefits paid to the employee.

06

Sign and date the form at the bottom before submission.

07

Submit the completed DWC-104 form to the appropriate state agency by the deadline.

Who needs dwc104?

01

Employers who are filing claim forms for workers' compensation injuries.

02

Employees who need to report workplace injuries or illnesses for compensation.

03

Insurance carriers managing claims related to workers' compensation cases.

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What is dwc104?

DWC-104 is a form used in California to report employee injury or illness claims to the Division of Workers' Compensation.

Who is required to file dwc104?

Employers in California are required to file DWC-104 if an employee has sustained a work-related injury or illness that necessitates reporting.

How to fill out dwc104?

To fill out DWC-104, employers must provide specific details about the employee, the nature of the injury or illness, and any relevant incident information, following the form's instructions.

What is the purpose of dwc104?

The purpose of DWC-104 is to provide necessary information to the Division of Workers' Compensation regarding employee claims for work-related injuries and to ensure compliance with California labor laws.

What information must be reported on dwc104?

The information that must be reported on DWC-104 includes the employee's details, date and location of the injury, a description of the injury, and any medical treatment provided.

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