Employee’s Claim Form DWC-1
Workers’ Compensation Claim Form for California Fair Employee Benefits
When a California fair employee suffers a job-related injury or illness, he or she could be eligible for Workers’ Compensation benefits. Completing a Claim form (DWC-1) is the first step in the process. By providing an employee with this form, you’re not admitting liability, but simply complying with the law.
When filling out the DWC-1 Claim form, California Fair Services Authority’s (CFSA’s) workers’ compensation administrator asks that you use the pre-printed form instead of printing copies of the online sample provided for your information only. If you’re low on printed forms, contact Chelsea Watts at (916) 263-6174 or email@example.com.
How to fill out the 2016 “Employee’s Claim Form for Workers’ Compensation Benefits” (DWC-1):
WITHIN ONE WORKING DAY of any knowledge of a work-related injury or illness:
An authorized fair representative must complete the Employer’s section (lower half) of the DWC-1 Claim Form before giving or mailing the form to the injured employee. State law does not require the employee to complete the form – it is the employee’s right to choose not to do so. The employee uses it to request workers’ compensation benefits. Returning the form is called “filing the claim form” and notifies the employer that the employee is pursuing workers’ compensation benefits.
- Do not fill in line 14 (line 13 on previous year forms) until the employee returns the form.
- Fill in line 13 (line 12 on previous year forms) with the date this claim form was given or mailed to the employee.
- Sign on line 17 (line 16 on previous year forms) when you have finished filling out the form.
Within 24 hours of receiving this form back from the injured/ill employee, the employer must finish the Employer’s section and send the form in for processing:
- Fill in line 14 (line 13 on previous year forms) with the date the form was received back from the employee.
- Fax a copy to CFSA: (916) 263-6159 as soon as possible in case we get a call about the accident, and then,
- Mail the canary copy to:
Attn: Workers’ Compensation Administrator
P.O. Box 15518
Sacramento, CA 95852-0518
You will find detailed instructions for completing the form as well as a completed sample on the front and back of the first page of the form itself.