Form DWC 1 (Chinese), the Workers' compensation claim form, is the Chinese-language version of the DWC-1 form that the California Division of Workers' Compensation (DWC), part of the Department of Industrial Relations (DIR), publishes for employees hurt or made ill by their job. The employee completes the "Employee" section and gives the form to the employer, who completes the rest. On this page you can fill out the form online on FillingPDF and download or print the completed PDF; the official PDF is published by the DWC.
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What is DWC 1?
Form DWC 1 (Chinese), the Workers' compensation claim form, is the California Division of Workers' Compensation form an employee uses to file a workers' compensation claim with the employer after a job-related injury or illness, printed with English and Chinese text.
The document has two parts. The cover pages are the Notice of Potential Eligibility, which explains the benefits an injured worker may be entitled to: medical care, temporary disability payments, permanent disability payments, the Supplemental Job Displacement Benefit (SJDB), and death benefits. The employee is told to detach this notice and keep it. The claim form itself follows, with an "Employee" section (lines 1 to 9) and an "Employer" section (lines 10 to 19).
Filing the form is how the employee tells the employer about the injury. The employer then dates the form, gives the employee a copy and sends a copy to the claims administrator, the party responsible for handling the claim. The form states that signing it is not an admission of liability.
The DWC lists the Workers' compensation claim form (DWC 1) in Spanish, Chinese, Korean, Tagalog and Vietnamese versions on its forms page. This page covers the Chinese version, revision 1/1/2016.
Who needs to file DWC 1?
Employees who are injured or become ill, physically or mentally, because of their job use this form to file a workers' compensation claim with their employer. The form says this includes injuries resulting from a workplace crime.
Others who take part:
- Employers complete the "Employer" section (lines 10 to 19). The form requires the employer to date it and give copies to the insurer or claims administrator and to the employee, dependent or representative who filed the claim, within one working day of receiving it from the employee.
- Dependents or representatives who file the claim are named in the employer's note as recipients of a copy. The form itself does not describe how someone else completes the Employee section.
- Claims administrators receive a copy and must tell the employee within 14 days whether the claim is accepted or needs more investigation.
Employees should complete only the Employee section and leave the rest for the employer. The Notice of Potential Eligibility says that, depending on the nature of the claim, you may be eligible for some or all of the benefits it lists.
When to file DWC 1
File the form right away after a job injury or illness. The Notice of Potential Eligibility tells the employee to complete the Employee section immediately to avoid problems with the claim, and says that in some cases benefits will not start until you inform your employer about your injury by filing a claim form. No other deadline is printed on the form.
Once the employee files the form, the employer must complete the Employer section, give the employee a dated copy, keep one copy and send one to the claims administrator within one working day. The claims administrator must then notify the employee within 14 days whether the claim is accepted or whether additional investigation is needed.
How to fill out DWC 1
Read the Notice of Potential Eligibility
The cover pages explain benefits, doctor choice and where to get help. Detach and save the notice for future reference; it is not part of what you give your employer.
Enter your name and today's date
On line 1, write your name and today's date in the Employee section. Complete only the Employee section; the Employer section is for your employer.
Enter your home address
Line 2 is your home address. On line 3, enter your city, state and ZIP code.
Give the date and time of injury
Line 4: the date of injury and the time of injury, marking a.m. or p.m.
Describe where the injury happened
Line 5: write the address and a description of the place where the injury happened.
Describe the injury and body parts
Line 6: describe the injury completely and include every part of your body affected.
Enter your Social Security number
Line 7: your Social Security Number, as the form asks.
Choose how to receive claim notices
Line 8: check the box only if you agree to receive notices about your claim by email only, and write your email on line 9. Without that choice, or if the claims administrator offers no electronic service, notices come by regular mail.
Keep your copy as a receipt
Keep one copy and mark it "Employee's Temporary Receipt" until your employer returns a signed and dated copy.
Leave lines 10 to 19 to your employer
The employer enters the employer's name and address, the dates it knew of the injury, provided and received the form, the insurance carrier or adjusting agency, policy number, signature, title and telephone.
Review and download the completed PDF
Check lines 1 to 9 for accuracy and completeness, then download or print the completed PDF from FillingPDF and give or mail it to your employer as described under How to submit.
How to submit DWC 1
The employee gives the completed Employee section to the employer, either by handing it over or by mailing it to the employer. The form names no portal, fax number or agency mailing address.
- To your employer: complete the Employee section, keep one copy, and give the rest to your employer. Mark your copy "Employee's Temporary Receipt" until the employer returns a signed and dated copy.
- By mail to your employer: use first-class or certified mail. If you buy a return receipt, you can prove the claim form was mailed and when it was delivered.
- After you file: the employer completes lines 10 to 19, gives you a dated copy, keeps one and sends one to the claims administrator. You do not send the form to the claims administrator yourself.
For recorded information, call the Division of Workers' Compensation at (800) 736-7401, or visit www.dwc.ca.gov to reach an Information & Assistance (I&A) officer. FillingPDF lets you fill out and download the PDF; submission follows the channels above.
Common mistakes to avoid
- Describing the injury incompletely. The form says to describe the injury completely and include every part of the body affected.
- Filling in the "Employer" section yourself; the form says to complete only the Employee section and leave the remainder for your employer.
- Mailing the form to your employer by an untraceable method; the notice says to use first-class or certified mail, and a return receipt proves mailing and delivery.
- Giving away every copy without keeping one marked "Employee's Temporary Receipt" until the employer returns the signed and dated copy.
- Waiting to report the injury; the notice says to file right away, and in some cases benefits will not start until you file a claim form.
- Employer failing to date the form and give copies to the insurer or claims administrator and to the employee within one working day of receipt.
- Checking line 8 (email notices only) without writing your email address on line 9, or later wanting mailed notices without telling your employer in writing.
- Entering knowingly false or fraudulent statements; the form warns that doing so for the purpose of obtaining or denying benefits is a felony.
Frequently asked questions
What is the DWC 1 claim form used for?
Form DWC 1 is the California workers' compensation claim form. An employee injured or made ill by the job completes the Employee section and gives the form to the employer, which starts the employer's duties to date the form and send a copy to the claims administrator.
Is there a Chinese version of the DWC 1 form?
Yes. The Division of Workers' Compensation publishes the DWC 1 in Chinese, printed with English and Chinese text. Its forms page also lists Spanish, Korean, Tagalog and Vietnamese versions of the Workers' compensation claim form.
Who fills out which part of the DWC 1?
The employee completes the Employee section (lines 1 to 9). The employer completes the Employer section (lines 10 to 19), including the insurance carrier or adjusting agency, policy number, and a representative's signature, title and telephone.
Where do I send the DWC 1 claim form?
Give it to your employer, or mail it to your employer by first-class or certified mail. The form lists no other address. The employer then sends a copy to the claims administrator, so you do not mail it there yourself.
How soon must my employer act after I file the DWC 1?
Within one working day after you file, the employer must complete its section, give you a dated copy, keep one copy and send one to the claims administrator. The claims administrator must then tell you within 14 days whether the claim is accepted or needs more investigation.
Does signing the DWC 1 mean the employer admits fault?
No. The form states that signing it is not an admission of liability. It also warns that knowingly making a false or fraudulent material statement to obtain or deny benefits is a felony.
Can I fill out Form DWC 1 (Chinese) online?
Yes. You can fill out the fillable PDF online on FillingPDF and download or print it. FillingPDF is independent of the DWC and does not submit the claim; you give or mail the form to your employer.
Can I get claim notices by email?
Yes, if your claims administrator offers it and you agree. Check line 8 and enter your email on line 9. Otherwise you receive notices by regular mail, and you can switch back to mail by informing your employer in writing.
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