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When a California fair employee suffers a job-related injury or illness, they
could be eligible for Workers' Compensation benefits. Completing
a Claim Form (DWC-1) is the first step in the process.
When filling out a claim form,
Patti Nevin, 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. If you're low on printed forms, contact Patti at 916/263-6172 or at pnevin@cfsa.org.
To take a look at the
sample, you'll need Adobe Reader, which you can download
for free from the Adobe
Web site.
How to fill out the "Employee's Claim Form for Workers' Compensation
Benefits" (DWC-1)
WITHIN THE FIRST 24 HOURS of any knowledge of a work-related
injury or illness:
An authorized employer representative must complete the Employer's
section (lower half) of the Claim Form before giving or mailing
the form to the injured employee. By completing this form you're
not admitting liability, but simply complying with the law. Some
tips:
- Do
not fill in line 13 until the employee returns the form.
- Fill
in line 12 with the date this claim form was given or mailed to
the employee.
-
Sign on line 16 when finished filling out the form.
Within 24 hours of receiving this form back from the injured/ill
employee:
- Fill
in line 13 with the date the form was received back from the employee.
- Mail CFSA's canary copy to:
CFSA
Attn: Workers' Compensation Administrator
P.O. Box 15518
Sacramento, CA 95852-0518
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Claim
Form