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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.
Forms are grouped by relevant subject, then in alphabetical order. Use the arrows to change to reverse alphabetical order or search by form number. The ten most-downloaded forms also appear in the “ Frequently used forms ” section.
Medical mileage expense form. If you need a medical mileage expense form for a year not listed here, please contact the Information and Assistance Unit at your closest district office of the Workers’ Compensation Appeals Board.
14 gru 2016 · An employee uses the Workers' Compensation Claim Form (DWC 1) & Notice of Potential Eligibility (e3301) to formally report a work-related injury or illness to his or her employer and to open a workers' compensation claim file.
• Provide the employee with Workers’ Compensation Claim Form (DWC 1) & Notice of Potential Eligibility form (e3301) within one working day of notice that a work-related injury or illness may have occurred; • Complete an Employer’s Report of Occupational Injury or Illness form (e3067) for all
14 wrz 2022 · Learn how to get workers’ comp benefits for an injury at work in California. Learn how to file a claim, what forms you must submit, & deadlines you must meet.
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.
