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’

Workers' compensation claim form. Spanish - Chinese - Korean - Tagalog - Vietnamese; DWC 1: Employer's report of occupational injury or illness: DLSR 5020: Petition for permission to negotiate a section 3201.7 labor-management agreement: DWC RGS-1

The Division of Workers' Compensation (DWC) monitors the administration of workers' compensation claims, and provides administrative and judicial services to assist in resolving disputes that arise in connection with claims for workers' compensation benefits.

• 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 …

If you are hurt at work, it is imperative that you report your work-related injury or illness, regardless of the nature or severity, to your supervisor immediately. Request an "Employee's Claim for Workers' Compensation Benefits" form from your supervisor (it's also known as a …