California Workers Compensation Forms to File

Understand the paperwork needed to complete your Worker's Compensation Form.

DWC-1 Claim Form

The main worker's comp claim form is form DWC-1, Workers’ Compensation Claim Form and Notice of Potential Eligibility. This form is similar to the initial complaint form in a lawsuit. Your employer is required to give you the claim form within one working day of hearing about a workplace injury that caused you to need treatment beyond basic first aid or caused you to miss work beyond the day of injury. If the employer does not provide you with the claim form, you can download a copy from the website of the Department of Workers’ Compensation (DWC). Form DWC-1 asks for straightforward information such as your name and address and the date, time, and location of your injury, as well as a description of the injury. Instructions for filling out the claim form can be found on the form itself. You submit this form to your employer after you are injured.

Predesignation of Personal Physician

If, before your injury, or before you report a slowly developing injury or illness, you want to designate the doctor or physician to treat you in case of workplace injury, you can submit this form to your employer, form DWC-9783, Predesignation of Personal Physician. You will be able to choose your own doctor only if your employer offers group health care, the doctor you designate is your personal physician who has treated you in the past and has your medical records, and your doctor agrees to treat you in the case of a work-related injury.

Application for Adjudication of Claim

You need to file this form, WCAB Form 1, Application for Adjudication of Claim, with the Workers’ Compensation Appeals Board, generally within one year of your date of injury. You’ll need to know the name of your employer’s insurance company for fill out this form; you should be able to find the name on the receipt of the DWC-1 claim form that your employer returned to you.

Declaration Pursuant to Labor Code 4906(g)

In this DWC form, Declaration Pursuant to Labor Code 4906(g), you swear that you haven’t bribed or otherwise made a doctor, hospital, or medical facility to submit any fraudulent information to the Department of Workers’ Compensation. You must submit this form when you submit an Application for Adjudication of Claim, above.

Declaration of Readiness to Proceed

Your employer’s insurance company or your worker’s compensation lawyer, if you have one, can use this Declaration of Readiness to Proceed form to request a hearing with the Worker’s Comp Appeals Board. Your lawyer might request a hearing if your claim was denied by your employer’s insurance company, you disagree with a doctor’s recommendation (say you think you need back surgery but the insurance company’s doctor does not), or you disagree with your permanent disability rating. Other reasons you might need to file a Declaration of Readiness to Proceed include a dispute over future medical treatment, supplemental job displacement benefits, or penalties for payment delays.

In some circumstances you may instead request an expedited hearing, using a form called a Declaration of Readiness to Proceed to Expedited Hearing (Trial). An expedited hearing can be requested only to solve a dispute over your entitlement to medical treatment or temporary disability benefits, but not a larger issue such as whether the insurance company must accept your claim. As there are certain guidelines you'll need to follow at your hearing, your chances of prevailing at a regular or expedited hearing increase if you bring a worker's comp lawyer.

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