Use the attached form to file a workers’ compensation claim with your employer. You should read all of the information below. Keep this sheet and all other papers for your records. You may be eligible for some or all of the benefits listed depending on the nature of your claim.

Filing of this application begins formal proceedings against the defendant(s) named in your application. You may request the assistance of an information and assistance officer of the …

Instructions for completing the Workers’ Compensation Claim Form (DWC 1) & Notice of Potential Eligibility (e3301) and the Employer’s Report of Occupational Injury or Illness (e3067). Attachments – Employee's Acknowledgment of Receipt, Witness Contact Sheet, and Customer Service Center Fax Cover Sheet (updated July 2012).

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Request an "Employee's Claim for Workers' Compensation Benefits" form from your supervisor (it's also known as a DWC 1 form). Your employer must give or mail you a claim form within one working day after learning about your injury or illness.

All employees should also have received a pamphlet describing workers' compensation benefits and procedures to obtain them. Members: To download this form, log in using the orange "Sign-In" button in the top-right corner of this page. Non-Members: Complete the fields below to receive your free form via email download.

DWC-1 Workers Compensation Claim Form. This is the form you will complete and send to EMPLOYERS to initiate the claim process for your employee. This form must be completed and provided to EMPLOYERS within one working day from you becoming aware of a work-related injury or occupational disease.

DWC Form-001, Employer s first report of injury or illness

California Code of Regulations, Title 8, Section § 10139. Workers' Compensation Claim Form (DWC 1) and Notice of Potential Eligibility. Chapter 4.5. Division of Workers' Compensation. SUBCHAPTER 1.5. INJURIES ON OR AFTER JANUARY 1, 1990. ARTICLE 9. CLAIM FORM: AVAILABILITY, FILING, ACKNOWLEDGEMENT OF RECEIPT, DISMISSAL. § 10139.