Article Structure
The DWC 1 form is an essential document for employees who have sustained injuries or illnesses related to their job. It serves as both a workers' compensation claim form and a notice of potential eligibility for benefits. When filling out this form, employees provide vital information about their injury, including the date, time, and location of the incident, as well as a detailed description of the injury itself. This information helps determine eligibility for various benefits, including medical care, temporary disability payments, and even death benefits in tragic cases. Employers are required to respond promptly to claims, typically within 14 days, to inform employees whether their claims have been accepted or if further investigation is needed. It is crucial for employees to complete the “Employee” section accurately and to keep a copy for their records. Timely submission of the form can significantly impact the benefits they receive, making it imperative to act quickly. The claims administrator will oversee the process, ensuring that necessary medical treatments are authorized and that employees are kept informed throughout their recovery journey.
Form Sample
§ 10139. Workers’ Compensation Claim Form (DWC 1) and Notice of Potential
Eligibility.
Note: Authority cited: Sections 133 5307.3 and 5401, Labor Code. Reference: Sections
132(a), 139.48, 139.6, 4600, 4600.3, 4601, 4604.5, 4616, 4650, 4656, 4658.5, 4658.6,
4700, 4701, 4702, 4703, 5400, 5401, 5401.7 and 5402, Labor Code.
Rev. 1/1/2016 Page 1 of 3
Workers’ Compensation Claim Form (DWC 1) & Notice of Potential Eligibility
Formulario de Reclamo de Compensación de Trabajadores (DWC 1) y Notificación de Posible Elegibilidad
If you are injured or become ill, either physically or mentally, because of your job,
including injuries resulting from a workplace crime, you may be entitled to
workers’ compensation benefits. 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. If you
file a claim, the claims administrator, who is responsible for handling your claim,
must notify you within 14 days whether your claim is accepted or whether
additional investigation is needed.
To file a claim, complete the “Employee” section of the form, keep one copy and
give the rest to your employer. Do this right away to avoid problems with your
claim. In some cases, benefits will not start until you inform your employer about
your injury by filing a claim form. Describe your injury completely. Include every
part of your body affected by the injury. If you mail the form to your employer,
use first-class or certified mail. If you buy a return receipt, you will be able to
prove that the claim form was mailed and when it was delivered. Within one
working day after you file the claim form, your employer must complete the
“Employer” section, give you a dated copy, keep one copy, and send one to the
claims administrator.
Medical Care: Your claims administrator will pay for all reasonable and
necessary medical care for your work injury or illness. Medical benefits are
subject to approval and may include treatment by a doctor, hospital services,
physical therapy, lab tests, x-rays, medicines, equipment and travel costs. Your
claims administrator will pay the costs of approved medical services directly so
you should never see a bill. There are limits on chiropractic, physical therapy, and
other occupational therapy visits.
The Primary Treating Physician (PTP) is the doctor with the overall
responsibility for treatment of your injury or illness.
If you previously designated your personal physician or a medical group,
you may see your personal physician or the medical group after you are
injured.
If your employer is using a medical provider network (MPN) or Health Care
Organization (HCO), in most cases, you will be treated in the MPN or HCO
unless you predesignated your personal physician or a medical group. An
MPN is a group of health care providers who provide treatment to workers
injured on the job. You should receive information from your employer if
you are covered by an HCO or a MPN. Contact your employer for more
information.
If your employer is not using an MPN or HCO, in most cases, the claims
administrator can choose the doctor who first treats you unless you
predesignated your personal physician or a medical group.
If your employer has not put up a poster describing your rights to workers’
compensation, you may be able to be treated by your personal physician
right after you are injured.
Within one working day after you file a claim form, your employer or the claims
administrator must authorize up to $10,000 in treatment for your injury, consistent
with the applicable treating guidelines until the claim is accepted or rejected. If
the employer or claims administrator does not authorize treatment right away, talk
to your supervisor, someone else in management, or the claims administrator. Ask
for treatment to be authorized right now, while waiting for a decision on your
claim. If the employer or claims administrator will not authorize treatment, use
your own health insurance to get medical care. Your health insurer will seek
reimbursement from the claims administrator. If you do not have health insurance,
there are doctors, clinics or hospitals that will treat you without immediate
payment. They will seek reimbursement from the claims administrator.
Switching to a Different Doctor as Your PTP:
If you are being treated in a Medical Provider Network (MPN), you may
switch to other doctors within the MPN after the first visit.
If you are being treated in a Health Care Organization (HCO), you may
switch at least one time to another doctor within the HCO. You may switch
to a doctor outside the HCO 90 or 180 days after your injury is reported to
your employer (depending on whether you are covered by employer-
provided health insurance).
If you are not being treated in an MPN or HCO and did not predesignate,
you may switch to a new doctor one time during the first 30 days after your
injury is reported to your employer. Contact the claims administrator to
switch doctors. After 30 days, you may switch to a doctor of your choice if
Si Ud. se lesiona o se enferma, ya sea físicamente o mentalmente, debido a su
trabajo, incluyendo lesiones que resulten de un crimen en el lugar de trabajo, es
posible que Ud. tenga derecho a beneficios de compensación de trabajadores.
Utilice el formulario adjunto para presentar un reclamo de compensación de
trabajadores con su empleador. Ud. debe leer toda la información a
continuación. Guarde esta hoja y todos los demás documentos para sus archivos.
Es posible que usted reúna los requisitos para todos los beneficios, o parte de
éstos, que se enumeran dependiendo de la índole de su reclamo. Si usted presenta
un reclamo, l administrador de reclamos, quien es responsable por el manejo de su
reclamo, debe notificarle dentro de 14 días si se acepta su reclamo o si se necesita
investigación adicional.
Para presentar un reclamo, llene la sección del formulario designada para el
“Empleado,” guarde una copia, y déle el resto a su empleador. Haga esto de
inmediato para evitar problemas con su reclamo. En algunos casos, los beneficios
no se iniciarán hasta que usted le informe a su empleador acerca de su lesión
mediante la presentación de un formulario de reclamo. Describa su lesión por
completo. Incluya cada parte de su cuerpo afectada por la lesión. Si usted le envía
por correo el formulario a su empleador, utilice primera clase o correo certificado.
Si usted compra un acuse de recibo, usted podrá demostrar que el formulario de
reclamo fue enviado por correo y cuando fue entregado. Dentro de un día laboral
después de presentar el formulario de reclamo, su empleador debe completar la
sección designada para el “Empleador,” le dará a Ud. una copia fechada, guardará
una copia, y enviará una al administrador de reclamos.
Atención Médica: Su administrador de reclamos pagará por toda la atención
médica razonable y necesaria para su lesión o enfermedad relacionada con el
trabajo. Los beneficios médicos están sujetos a la aprobación y pueden incluir
tratamiento por parte de un médico, los servicios de hospital, la terapia física, los
análisis de laboratorio, las medicinas, equipos y gastos de viaje. Su administrador
de reclamos pagará directamente los costos de los servicios médicos aprobados de
manera que usted nunca verá una factura. Hay límites en terapia quiropráctica,
física y otras visitas de terapia ocupacional.
El Médico Primario que le Atiende (Primary Treating Physician- PTP) es el
médico con la responsabilidad total para tratar su lesión o enfermedad.
Si usted designó previamente a su médico personal o a un grupo médico,
usted podrá ver a su médico personal o grupo médico después de lesionarse.
Si su empleador está utilizando una red de proveedores médicos (Medical
Provider Network- MPN) o una Organización de Cuidado Médico (Health
Care Organization- HCO), en la mayoría de los casos, usted será tratado en
la MPN o HCO a menos que usted hizo una designación previa de su médico
personal o grupo médico. Una MPN es un grupo de proveedores de
asistencia médica quien da tratamiento a los trabajadores lesionados en el
trabajo. Usted debe recibir información de su empleador si su tratamiento es
cubierto por una HCO o una MPN. Hable con su empleador para más
información.
Si su empleador no está utilizando una MPN o HCO, en la mayoría de los
casos, el administrador de reclamos puede elegir el médico que lo atiende
primero a menos de que usted hizo una designación previa de su médico
personal o grupo médico.
Si su empleador no ha colocado un cartel describiendo sus derechos para la
compensación de trabajadores, Ud. puede ser tratado por su médico personal
inmediatamente después de lesionarse.
Dentro de un día laboral después de que Ud. Presente un formulario de reclamo,
su empleador o el administrador de reclamos debe autorizar hasta $10000 en
tratamiento para su lesión, de acuerdo con las pautas de tratamiento aplicables,
hasta que el reclamo sea aceptado o rechazado. Si el empleador o administrador
de reclamos no autoriza el tratamiento de inmediato, hable con su supervisor,
alguien más en la gerencia, o con el administrador de reclamos. Pida que el
tratamiento sea autorizado ya mismo, mientras espera una decisión sobre su
reclamo. Si el empleador o administrador de reclamos no autoriza el tratamiento,
utilice su propio seguro médico para recibir atención médica. Su compañía de
seguro médico buscará reembolso del administrador de reclamos. Si usted no
tiene seguro médico, hay médicos, clínicas u hospitales que lo tratarán sin pago
inmediato. Ellos buscarán reembolso del administrador de reclamos.
Cambiando a otro Médico Primario o PTP:
Si usted está recibiendo tratamiento en una Red de Proveedores Médicos
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your employer or the claims administrator has not created or selected an
MPN.
Disclosure of Medical Records: After you make a claim for workers'
compensation benefits, your medical records will not have the same level of
privacy that you usually expect. If you don’t agree to voluntarily release medical
records, a workers’ compensation judge may decide what records will be released.
If you request privacy, the judge may "seal" (keep private) certain medical
records.
Problems with Medical Care and Medical Reports: At some point during your
claim, you might disagree with your PTP about what treatment is necessary. If
this happens, you can switch to other doctors as described above. If you cannot
reach agreement with another doctor, the steps to take depend on whether you are
receiving care in an MPN, HCO, or neither. For more information, see “Learn
More About Workers’ Compensation,” below.
If the claims administrator denies treatment recommended by your PTP, you may
request independent medical review (IMR) using the request form included with
the claims administrator’s written decision to deny treatment. The IMR process is
similar to the group health IMR process, and takes approximately 40 (or fewer)
days to arrive at a determination so that appropriate treatment can be given. Your
attorney or your physician may assist you in the IMR process. IMR is not
available to resolve disputes over matters other than the medical necessity of a
particular treatment requested by your physician.
If you disagree with your PTP on matters other than treatment, such as the cause
of your injury or how severe the injury is, you can switch to other doctors as
described above. If you cannot reach agreement with another doctor, notify the
claims administrator in writing as soon as possible. In some cases, you risk losing
the right to challenge your PTP’s opinion unless you do this promptly. If you do
not have an attorney, the claims administrator must send you instructions on how
to be seen by a doctor called a qualified medical evaluator (QME) to help resolve
the dispute. If you have an attorney, the claims administrator may try to reach
agreement with your attorney on a doctor called an agreed medical evaluator
(AME). If the claims administrator disagrees with your PTP on matters other than
treatment, the claims administrator can require you to be seen by a QME or AME.
Payment for Temporary Disability (Lost Wages): If you can't work while you
are recovering from a job injury or illness, you may receive temporary disability
payments for a limited period. These payments may change or stop when your
doctor says you are able to return to work. These benefits are tax-free. Temporary
disability payments are two-thirds of your average weekly pay, within minimums
and maximums set by state law. Payments are not made for the first three days
you are off the job unless you are hospitalized overnight or cannot work for more
than 14 days.
Stay at Work or Return to Work: Being injured does not mean you must stop
working. If you can continue working, you should. If not, it is important to go
back to work with your current employer as soon as you are medically able.
Studies show that the longer you are off work, the harder it is to get back to your
original job and wages. While you are recovering, your PTP, your employer
(supervisors or others in management), the claims administrator, and your
attorney (if you have one) will work with you to decide how you will stay at work
or return to work and what work you will do. Actively communicate with your
PTP, your employer, and the claims administrator about the work you did before
you were injured, your medical condition and the kinds of work you can do now,
and the kinds of work that your employer could make available to you.
Payment for Permanent Disability: If a doctor says you have not recovered
completely from your injury and you will always be limited in the work you can
do, you may receive additional payments. The amount will depend on the type of
injury, extent of impairment, your age, occupation, date of injury, and your wages
before you were injured.
Supplemental Job Displacement Benefit (SJDB): If you were injured on or
after 1/1/04, and your injury results in a permanent disability and your employer
does not offer regular, modified, or alternative work, you may qualify for a
nontransferable voucher payable for retraining and/or skill enhancement. If you
qualify, the claims administrator will pay the costs up to the maximum set by state
law.
Death Benefits: If the injury or illness causes death, payments may be made to a
(Medical Provider Network- MPN), usted puede cambiar a otros médicos
dentro de la MPN después de la primera visita.
Si usted está recibiendo tratamiento en un Organización de Cuidado Médico
(Healthcare Organization- HCO), es posible cambiar al menos una vez a otro
médico dentro de la HCO. Usted puede cambiar a un médico fuera de la
HCO 90 o 180 días después de que su lesión es reportada a su empleador
(dependiendo de si usted está cubierto por un seguro médico proporcionado
por su empleador).
Si usted no está recibiendo tratamiento en una MPN o HCO y no hizo una
designación previa, usted puede cambiar a un nuevo médico una vez durante
los primeros 30 días después de que su lesión es reportada a su empleador.
Póngase en contacto con el administrador de reclamos para cambiar de
médico. Después de 30 días, puede cambiar a un médico de su elección si su
empleador o el administrador de reclamos no ha creado o seleccionado una
MPN.
Divulgación de Expedientes Médicos: Después de que Ud. presente un reclamo
para beneficios de compensación de trabajadores, sus expedientes médicos no
tendrán el mismo nivel de privacidad que usted normalmente espera. Si Ud. no
está de acuerdo en divulgar voluntariamente los expedientes médicos, un juez de
compensación de trabajadores posiblemente decida qué expedientes serán
revelados. Si usted solicita privacidad, es posible que el juez “selle” (mantenga
privados) ciertos expedientes médicos.
Problemas con la Atención Médica y los Informes Médicos: En algún
momento durante su reclamo, podría estar en desacuerdo con su PTP sobre qué
tratamiento es necesario. Si esto sucede, usted puede cambiar a otros médicos
como se describe anteriormente. Si no puede llegar a un acuerdo con otro médico,
los pasos a seguir dependen de si usted está recibiendo atención en una MPN,
HCO o ninguna de las dos. Para más información, consulte la sección “Aprenda
Más Sobre la Compensación de Trabajadores,” a continuación.
Si el administrador de reclamos niega el tratamiento recomendado por su PTP,
puede solicitar una revisión médica independiente (Independent Medical Review-
IMR), utilizando el formulario de solicitud que se incluye con la decisión por
escrito del administrador de reclamos negando el tratamiento. El proceso de la
IMR es parecido al proceso de la IMR de un seguro médico colectivo, y tarda
aproximadamente 40 (o menos) días para llegar a una determinación de manera
que se pueda dar un tratamiento apropiado. Su abogado o su médico le pueden
ayudar en el proceso de la IMR. La IMR no está disponible para resolver disputas
sobre cuestiones aparte de la necesidad médica de un tratamiento particular
solicitado por su médico.
Si no está de acuerdo con su PTP en cuestiones aparte del tratamiento, como la
causa de su lesión o la gravedad de la lesión, usted puede cambiar a otros médicos
como se describe anteriormente. Si no puede llegar a un acuerdo con otro médico,
notifique al administrador de reclamos por escrito tan pronto como sea posible.
En algunos casos, usted arriesg perder el derecho a objetar a la opinión de su PTP
a menos que hace esto de inmediato. Si usted no tiene un abogado, el
administrador de reclamos debe enviarle instrucciones para ser evaluado por un
médico llamado un evaluador médico calificado (Qualified Medical Evaluator-
QME) para ayudar a resolver la disputa. Si usted tiene un abogado, el
administrador de reclamos puede tratar de llegar a un acuerdo con su abogado
sobre un médico llamado un evaluador médico acordado (Agreed Medical
Evaluator- AME). Si el administrador de reclamos no está de acuerdo con su PTP
sobre asuntos aparte del tratamiento, el administrador de reclamos puede exigirle
que sea atendido por un QME o AME.
Pago por Incapacidad Temporal (Sueldos Perdidos): Si Ud. no puede trabajar,
mientras se está recuperando de una lesión o enfermedad relacionada con el
trabajo, Ud. puede recibir pagos por incapacidad temporal por un periodo
limitado. Estos pagos pueden cambiar o parar cuando su médico diga que Ud. está
en condiciones de regresar a trabajar. Estos beneficios son libres de impuestos.
Los pagos por incapacidad temporal son dos tercios de su pago semanal promedio,
con cantidades mínimas y máximas establecidas por las leyes estales. Los pagos
no se hacen durante los primeros tres días en que Ud. no trabaje, a menos que Ud.
sea hospitalizado una noche o no puede trabajar durante más de 14 días.
Permanezca en el Trabajo o Regreso al Trabajo: Estar lesionado no significa
que usted debe dejar de trabajar. Si usted puede seguir trabajando, usted debe
hacerlo. Si no es así, es importante regresar a trabajar con su empleador actual tan
Rev. 1/1/2016 Page 3 of 3
spouse and other relatives or household members who were financially dependent
on the deceased worker.
It is illegal for your employer to punish or fire you for having a job injury or
illness, for filing a claim, or testifying in another person's workers' compensation
case (Labor Code 132a). If proven, you may receive lost wages, job reinstatement,
increased benefits, and costs and expenses up to limits set by the state.
Resolving Problems or Disputes: You have the right to disagree with decisions
affecting your claim. If you have a disagreement, contact your employer or claims
administrator first to see if you can resolve it. If you are not receiving benefits,
you may be able to get State Disability Insurance (SDI) or unemployment
insurance (UI) benefits. Call the state Employment Development Department at
(800) 480-3287 or (866) 333-4606, or go to their website at www.edd.ca.gov.
You Can Contact an Information & Assistance (I&A) Officer: State I&A
officers answer questions, help injured workers, provide forms, and help resolve
problems. Some I&A officers hold workshops for injured workers. To obtain
important information about the workers’ compensation claims process and your
rights and obligations, go to www.dwc.ca.gov or contact an I&A officer of the
state Division of Workers’ Compensation. You can also hear recorded information
and a list of local I&A offices by calling (800) 736-7401.
You can consult with an attorney. Most attorneys offer one free consultation. If
you decide to hire an attorney, his or her fee will be taken out of some of your
benefits. For names of workers' compensation attorneys, call the State Bar of
California at (415) 538-2120 or go to their website at www.
californiaspecialist.org.
Learn More About Workers’ Compensation: For more information about the
workers’ compensation claims process, go to www.dwc.ca.gov. At the website,
you can access a useful booklet, “Workers’ Compensation in California: A
Guidebook for Injured Workers.” You can also contact an Information &
Assistance Officer (above), or hear recorded information by calling 1-800-736-
7401.
pronto como usted pueda medicamente hacerlo. Los estudios demuestran que
entre más tiempo esté fuera del trabajo, más difícil es regresar a su trabajo original
y a sus salarios. Mientras se está recuperando, su PTP, su empleador
(supervisores u otras personas en la gerencia), el administrador de reclamos, y su
abogado (si tiene uno) trabajarán con usted para decidir cómo va a permanecer en
el trabajo o regresar al trabajo y qué trabajo hará. Comuníquese de manera activa
con su PTP, su empleador y el administrador de reclamos sobre el trabajo que
hizo antes de lesionarse, su condición médica y los tipos de trabajo que usted
puede hacer ahora y los tipos de trabajo que su empleador podría poner a su
disposición.
Pago por Incapacidad Permanente: Si un médico dice que no se ha recuperado
completamente de su lesión y siempre será limitado en el trabajo que puede hacer,
es posible que Ud. reciba pagos adicionales. La cantidad dependerá de la clase de
lesión, grado de deterioro, su edad, ocupación, fecha de la lesión y sus salarios
antes de lesionarse.
Beneficio Suplementario por Desplazamiento de Trabajo (Supplemental Job
Displacement Benefit- SJDB): Si Ud. se lesionó en o después del 1/1/04, y su
lesión resulta en una incapacidad permanente y su empleador no ofrece un trabajo
regular, modificado, o alternativo, usted podría cumplir los requisitos para recibir
un vale no-transferible pagadero a una escuela para recibir un nuevo un curso de
reentrenamiento y/o mejorar su habilidad. Si Ud. cumple los requisios, el
administrador de reclamos pagará los gastos hasta un máximo establecido por las
leyes estatales.
Beneficios por Muerte: Si la lesión o enfermedad causa la muerte, es posible que
los pagos se hagan a un cónyuge y otros parientes o a las personas que viven en el
hogar que dependían económicamente del trabajador difunto.
Es ilegal que su empleador le castigue o despida por sufrir una lesión o
enfermedad laboral, por presentar un reclamo o por testificar en el caso de
compensación de trabajadores de otra persona. (Código Laboral, sección 132a.)
De ser probado, usted puede recibir pagos por pérdida de sueldos, reposición del
trabajo, aumento de beneficios y gastos hasta los límites establecidos por el
estado.
Resolviendo problemas o disputas: Ud. tiene derecho a no estar de acuerdo con
las decisiones que afecten su reclamo. Si Ud. tiene un desacuerdo, primero
comuníquese con su empleador o administrador de reclamos para ver si usted
puede resolverlo. Si usted no está recibiendo beneficios, es posible que Ud. pueda
obtener beneficios del Seguro Estatalde Incapacidad (State Disability Insurance-
SDI) o beneficios del desempleo (Unemployment Insurance- UI). Llame al
Departamento del Desarrollo del Empleo estatal al (800) 480-3287 o (866) 333-
4606, o visite su página Web en www.edd.ca.gov.
Puede Contactar a un Oficial de Información y Asistencia (Information &
Assistance- I&A): Los Oficiales de Información y Asistencia (I&A) estatal
contestan preguntas, ayudan a los trabajadores lesionados, proporcionan
formularios y ayudan a resolver problemas. Algunos oficiales de I&A tienen
talleres para trabajadores lesionados. Para obtener información importante sobre
el proceso de la compensación de trabajadores y sus derechos y obligaciones, vaya
a www.dwc.ca.gov o comuníquese con un oficial de información y asistencia de la
División Estatal de Compensación de Trabajadores. También puede escuchar
información grabada y una lista de las oficinas de I&A locales llamando al (800)
736-7401.
Ud. puede consultar con un abogado. La mayoría de los abogados ofrecen una
consulta gratis. Si Ud. decide contratar a un abogado, los honorarios serán
tomados de algunos de sus beneficios. Para obtener nombres de abogados de
compensación de trabajadores, llame a la Asociación Estatal de Abogados de
California (State Bar) al (415) 538-2120, o consulte su página Web en
www.californiaspecialist.org.
Aprenda Más Sobre la Compensación de Trabajadores: Para obtener más
información sobre el proceso de reclamos del programa de compensación de
trabajadores, vaya a www.dwc.ca.gov. En la página Web, podrá acceder a un
folleto útil, “Compensación del Trabajador de California: Una Guía para
Trabajadores Lesionados.” También puede contactar a un oficial de Información
y Asistencia (arriba), o escuchar información grabada llamando al 1-800-736-
7401.
.
Rev. 1/1/2016
State of California
Department of Industrial Relations
DIVISION OF WORKERS’ COMPENSATION
WORKERS’ COMPENSATION CLAIM FORM (DWC 1)
Estado de California
Departamento de Relaciones Industriales
DIVISION DE COMPENSACIÓN AL TRABAJADOR
PETITION DEL EMPLEADO PARA DE COMPENSACIÓN DEL
TRABAJADOR (DWC 1)
Employee: Complete the “Employee” section and give the form to your
employer. Keep a copy and mark it “Employee’s Temporary Receipt” until
you receive the signed and dated copy from your employer. You may call the
Division of Workers’ Compensation and hear recorded information at (800)
736-7401. An explanation of workers' compensation benefits is included in
the Notice of Potential Eligibility, which is the cover sheet of this form.
Detach and save this notice for future reference.
You should also have received a pamphlet from your employer describing
workers’ compensation benefits and the procedures to obtain them. You may
receive written notices from your employer or its claims administrator about
your claim. If your claims administrator offers to send you notices
electronically, and you agree to receive these notices only by email, please
provide your email address below and check the appropriate box. If you later
decide you want to receive the notices by mail, you must inform your
employer in writing.
Empleado: Complete la sección “Empleado” y entregue la forma a su
empleador. Quédese con la copia designada “Recibo Temporal del
Empleado” hasta que Ud. reciba la copia firmada y fechada de su empleador.
Ud. puede llamar a la Division de Compensación al Trabajador al (800) 736-
7401 para oir información gravada. Una explicación de los beneficios de
compensación de trabajadores está incluido en la Notificación de Posible
Elegibilidad, que es la hoja de portada de esta forma. Separe y guarde esta
notificación como referencia para el futuro.
Ud. también debería haber recibido de su empleador un folleto describiendo
los benficios de compensación al trabajador lesionado y los procedimientos
para obtenerlos. Es posible que reciba notificaciones escritas de su
empleador o de su administrador de reclamos sobre su reclamo. Si su
administrador de reclamos ofrece enviarle notificaciones electrónicamente, y
usted acepta recibir estas notificaciones solo por correo electrónico, por
favor proporcione su dirección de correo electrónico abajo y marque la caja
apropiada. Si usted decide después que quiere recibir las notificaciones por
correo, usted debe de informar a su empleador por escrito.
Any person who makes or causes to be made any knowingly false or
fraudulent material statement or material representation for the
purpose of obtaining or denying workers’ compensation benefits or
payments is guilty of a felony.
Toda aquella persona que a propósito haga o cause que se produzca
cualquier declaración o representación material falsa o fraudulenta con
el fin de obtener o negar beneficios o pagos de compensación a
trabajadores lesionados es culpable de un crimen mayor “felonia”.
Employee—complete this section and see note above Empleado—complete esta sección y note la notación arriba.
1. Name. Nombre. ___________________________________________________ Today’s Date. Fecha de Hoy. ____________________________________________
2. Home Address. Dirección Residencial. _____________________________________________________________________________________________________
3. City. Ciudad. _______________________________________ State. Estado. _____________________ Zip. Código Postal. ______________________________
4. Date of Injury. Fecha de la lesión (accidente). ________________________________ Time of Injury. Hora en que ocurrió. ____________a.m. ___________p.m.
5. Address and description of where injury happened. Dirección/lugar dónde occurió el accidente. _______________________________________________________
_______________________________________________________________________________________________________________________________________
6. Describe injury and part of body affected. Describa la lesión y parte del cuerpo afectada. ____________________________________________________________
_______________________________________________________________________________________________________________________________________
7. Social Security Number. Número de Seguro Social del Empleado. _______________________________________________________________________________
8.
Check if you agree to receive notices about your claim by email only. Marque si usted acepta recibir notificaciones sobre su reclamo solo por correo
electrónico. Employee’s e-mail. _____________________________________ Correo electrónico del empleado. __________________________________________.
You will receive benefit notices by regular mail if you do not choose, or your claims administrator does not offer, an electronic service option. Usted recibirá
notificaciones de beneficios por correo ordinario si usted no escoge, o su administrador de reclamos no le ofrece, una opción de servicio electrónico.
9. Signature of employee. Firma del empleado. ________________________________________________________________________________________________
Employer—complete this section and see note below. Empleador—complete esta sección y note la notación abajo.
10. Name of employer. Nombre del empleador. ________________________________________________________________________________________________
11. Address. Dirección. __________________________________________________________________________________________________________________
12. Date employer first knew of injury. Fecha en que el empleador supo por primera vez de la lesión o accidente. ___________________________________________
13. Date claim form was provided to employee. Fecha en que se le entregó al empleado la petición. ______________________________________________________
14. Date employer received claim form. Fecha en que el empleado devolvió la petición al empleador._____________________________________________________
15. Name and address of insurance carrier or adjusting agency. Nombre y dirección de la compañía de seguros o agencia adminstradora de seguros. _______________
_______________________________________________________________________________________________________________________________________
16. Insurance Policy Number. El número de la póliza de Seguro.___________________________________________________________________________________
17. Signature of employer representative. Firma del representante del empleador. ____________________________________________________________________
18. Title. Título. _________________________________________ 19. Telephone. Teléfono. ___________________________________________________________
Employer: You are required to date this form and provide copies to your insurer
or claims administrator and to the employee, dependent or representative who
filed the claim within one working day of receipt of the form from the employee.
SIGNING THIS FORM IS NOT AN ADMISSION OF LIABILITY
Empleador: Se requiere que Ud. feche esta forma y que provéa copias a su
compañía de seguros, administrador de reclamos, o dependiente/representante de
reclamos y al empleado que hayan presentado esta petición dentro del plazo de
un día hábil desde el momento de haber sido recibida la forma del empleado.
EL FIRMAR ESTA FORMA NO SIGNIFICA ADMISION DE RESPONSABILIDAD
Employer copy/Copia del Empleador Employee copy/Copia del Empleado Claims Administrator/Administrador de Reclamos Temporary Receipt/Recibo del Empleado
Document Specifications
| Fact Name | Details |
|---|---|
| Form Purpose | The DWC 1 form is used to file a workers' compensation claim in California, allowing employees to report job-related injuries or illnesses. |
| Eligibility Notification | Claims administrators must notify employees within 14 days whether their claim is accepted or if further investigation is required. |
| Medical Treatment Authorization | Employers or claims administrators are required to authorize up to $10,000 in medical treatment for the injury within one working day after filing the claim. |
| Benefits Coverage | Medical benefits cover reasonable and necessary treatment, including doctor visits, physical therapy, and medications, with costs paid directly by the claims administrator. |
| Temporary Disability Payments | Employees unable to work due to their injury may receive temporary disability payments, which are typically two-thirds of their average weekly pay. |
| Disclosure of Medical Records | Upon filing a claim, medical records may be disclosed without the same level of privacy as before, unless a judge seals certain records. |
| Governing Laws | The DWC 1 form is governed by various sections of the California Labor Code, including Sections 132(a), 139.48, and 5401. |
Steps to Filling Out Dwc 1
Filling out the DWC 1 form is an essential step in filing a workers' compensation claim. It is important to provide accurate and complete information to ensure that your claim is processed efficiently. Follow the steps below to complete the form correctly.
- Employee Section: Start by filling out the “Employee” section of the form. Provide your name, today's date, and your home address, including city, state, and zip code.
- Date and Time of Injury: Enter the date and time of your injury. Specify whether it occurred in the morning or afternoon.
- Injury Location: Describe the address and location where the injury happened.
- Description of Injury: Clearly describe your injury and specify which part of your body is affected.
- Social Security Number: Provide your Social Security number in the designated space.
- Email Notification: If you agree to receive notices about your claim by email, check the appropriate box and enter your email address.
- Employee Signature: Sign the form to confirm that the information provided is accurate.
Once you have completed the employee section, make a copy for your records and give the original form to your employer. Your employer will then complete their section of the form and must provide you with a signed and dated copy within one working day. Keep this copy for your records as it will serve as proof of your claim submission.
More About Dwc 1
What is the DWC 1 form?
The DWC 1 form, or Workers' Compensation Claim Form, is a document used by employees to file a claim for workers' compensation benefits. If you are injured or become ill due to your job, you can use this form to notify your employer and initiate the claims process. The form must be filled out completely, including details about the injury, and submitted to your employer as soon as possible.
How do I fill out the DWC 1 form?
To complete the DWC 1 form, start by filling out the "Employee" section. Provide your name, address, and details about the injury, including the date, time, and location. Describe the injury and which parts of your body are affected. After filling out your section, keep a copy for your records and give the form to your employer. They will complete their section and provide you with a signed copy.
What happens after I submit the DWC 1 form?
Once you submit the DWC 1 form to your employer, they have one working day to complete their section and return a dated copy to you. The claims administrator, responsible for processing your claim, must notify you within 14 days whether your claim has been accepted or if more investigation is needed. If your claim is accepted, you may begin receiving benefits for medical care and lost wages.
What benefits can I receive through the DWC 1 form?
The benefits available through a workers' compensation claim may include medical care for your injury, temporary disability payments if you cannot work, and potentially permanent disability payments if your injury results in lasting effects. You may also qualify for a Supplemental Job Displacement Benefit if your employer does not offer you suitable work after your injury.
What if my employer does not authorize medical treatment?
If your employer or the claims administrator does not authorize medical treatment immediately after you file your claim, you can ask for authorization from your supervisor or the claims administrator. If they still do not authorize treatment, you can use your own health insurance to receive care, and your insurer will seek reimbursement from the claims administrator.
Can I change my doctor after filing the DWC 1 form?
Yes, you can change your doctor under certain conditions. If you are treated within a Medical Provider Network (MPN) or Health Care Organization (HCO), you may switch to another doctor within that network after your first visit. If you are not in an MPN or HCO and did not predesignate a doctor, you can switch to a new doctor once within the first 30 days after reporting your injury. After 30 days, you may choose a doctor of your choice.
Common mistakes
-
Incomplete Personal Information: Many individuals neglect to fill in all required personal details, such as their full name, address, and Social Security number. Omitting this information can delay the processing of the claim.
-
Vague Description of Injury: Failing to provide a detailed description of the injury can lead to misunderstandings. It is crucial to specify the exact nature of the injury and all affected body parts.
-
Not Keeping Copies: Some people forget to keep a copy of the completed DWC 1 form for their records. Retaining a copy is essential for tracking the claim and ensuring that all parties have the necessary documentation.
-
Delaying Submission: Submitting the form late can lead to complications. It is important to file the claim promptly to avoid issues with benefit eligibility.
-
Ignoring Employer's Section: Individuals often overlook the importance of the employer's section of the form. This part must be completed by the employer within one working day of receiving the claim, and it is essential for moving forward with the claim process.
Documents used along the form
When filing a workers' compensation claim, the DWC 1 form is essential. However, several other documents often accompany it, facilitating the claims process and ensuring that all necessary information is collected. Below is a list of additional forms and documents commonly used in conjunction with the DWC 1 form.
- Claim Form (DWC 1A): This form is used to provide additional information about the claim. It may include details about the injury, treatment, and other relevant circumstances that can assist in the evaluation of the claim.
- Medical Report: A medical report from the treating physician outlines the nature of the injury, the treatment provided, and the prognosis. This document is crucial for determining the medical benefits owed to the injured worker.
- Employer’s Report of Injury (DWC 1ER): This report is completed by the employer and provides details about the incident, including when and where it occurred. It helps the claims administrator understand the context of the injury.
- Notice of Potential Eligibility: This notice accompanies the DWC 1 form and informs the injured worker about their potential rights and benefits under the workers' compensation system. It serves as a guide to understanding the next steps in the claims process.
- Return-to-Work Form: This form is used when the injured worker is ready to return to their job. It may include any necessary restrictions or accommodations required for the worker to safely resume their duties.
- Temporary Disability Claim Form: If the injured worker is unable to work due to their injury, this form is used to apply for temporary disability benefits. It outlines the duration of the disability and the compensation being requested.
- Supplemental Job Displacement Benefit Voucher: For workers who sustain permanent disabilities and are not offered suitable work, this voucher assists with retraining or skill enhancement. It helps facilitate a smoother transition back into the workforce.
- Death Claim Form: In the unfortunate event that a work-related injury leads to death, this form allows dependents to claim benefits. It outlines the relationship to the deceased and the compensation sought.
Each of these documents plays a vital role in the workers' compensation process. They ensure that both the injured worker and the employer are adequately represented and that all necessary information is available for a fair evaluation of the claim. Being prepared with these forms can significantly streamline the claims process and help in obtaining the benefits due.
Similar forms
The DWC 1 form shares similarities with the Employee's Report of Injury form. Both documents serve to initiate a workers' compensation claim by allowing employees to report their injuries or illnesses. The Employee's Report of Injury form typically requires details about the injury, including the time and place it occurred, similar to the DWC 1 form. This ensures that employers have the necessary information to address the claim promptly and accurately.
Another related document is the Employer's Report of Injury form. This form is completed by the employer after receiving the DWC 1 form. It captures the employer's perspective on the incident and provides essential information about the workplace environment. Like the DWC 1, it is crucial for processing the claim and ensuring that both parties are aligned on the facts surrounding the injury.
The Claim for Compensation form is also akin to the DWC 1 form. This document is often used to formally request benefits after an injury has been reported. It requires similar information about the employee's condition and the circumstances of the injury. Both forms aim to ensure that the injured worker receives the benefits they are entitled to under workers' compensation laws.
The Medical Authorization form is another document that parallels the DWC 1 form. It allows the claims administrator to access the injured worker's medical records. This is important for verifying the injury and determining the appropriate benefits. Like the DWC 1, this form is essential for the claims process and helps facilitate communication between medical providers and the claims administrator.
The Notice of Potential Eligibility is similar to the DWC 1 form in that it provides crucial information about the rights and benefits available to injured workers. This notice is typically attached to the DWC 1 form and outlines the types of benefits an employee may be eligible for, ensuring that they are informed about their options right from the start of the claims process.
The Independent Medical Review (IMR) request form is another related document. If there is a disagreement about the medical treatment required, this form allows the injured worker to seek an independent evaluation. The IMR process is designed to resolve disputes about medical necessity, much like the DWC 1 form aims to address the initial claim for benefits.
Lastly, the Supplemental Job Displacement Benefit (SJDB) voucher is connected to the DWC 1 form. If an employee suffers a permanent disability and cannot return to their previous job, they may qualify for this benefit. The SJDB voucher helps cover retraining costs, similar to how the DWC 1 form initiates the process for receiving various forms of compensation for work-related injuries.
Dos and Don'ts
When filling out the DWC 1 form, it is essential to follow certain guidelines to ensure a smooth claims process. Here are seven important things to do and avoid:
- Do complete the “Employee” section accurately and thoroughly.
- Do describe your injury in detail, including all affected body parts.
- Do keep a copy of the completed form for your records.
- Do submit the form to your employer as soon as possible.
- Do use certified or first-class mail if sending the form by mail.
- Don't leave any sections blank; ensure all required fields are filled out.
- Don't delay in reporting your injury to your employer, as this can affect your benefits.
Following these steps can help streamline the process and protect your rights as an injured worker.
Misconceptions
- Misconception 1: The DWC 1 form is only for physical injuries.
- Misconception 2: Filing the DWC 1 form guarantees immediate benefits.
- Misconception 3: You can wait to file the DWC 1 form at your convenience.
- Misconception 4: You can choose any doctor after filing the DWC 1 form.
- Misconception 5: You will always receive a bill for medical services.
- Misconception 6: You cannot switch doctors once treatment begins.
This form is applicable for both physical and mental injuries resulting from job-related incidents, including workplace crimes.
Benefits are not guaranteed upon filing. The claims administrator must review the claim and notify you within 14 days about its acceptance or the need for further investigation.
It’s crucial to file the form as soon as possible. Delaying could jeopardize your eligibility for benefits.
Your choice of doctor may be limited based on whether your employer uses a Medical Provider Network (MPN) or Health Care Organization (HCO).
For approved medical services related to your claim, the claims administrator pays directly, so you should not receive any bills.
You may switch doctors under certain conditions, especially if you are within a MPN or HCO, or if you have not predesignated a physician.
Key takeaways
The DWC 1 form is essential for filing a workers’ compensation claim if you are injured or become ill due to your job.
Complete the “Employee” section of the form accurately and thoroughly, describing your injury and the affected body parts.
Submit the form to your employer as soon as possible to avoid delays in your claim process.
Your employer must notify you within 14 days if your claim is accepted or if further investigation is needed.
Keep a copy of the form marked as “Employee’s Temporary Receipt” until you receive a signed copy from your employer.
If your claim is approved, your claims administrator will cover reasonable medical expenses related to your injury without you seeing a bill.
In case of disputes regarding treatment or other issues, you have the right to seek assistance from a qualified medical evaluator or an attorney.