Form DWC 1, Workers' compensation claim form (Vietnamese), is the Vietnamese-language edition of the California DWC-1 form, the claim form an injured or ill employee gives to the employer. It is issued by the Division of Workers' Compensation (DWC) of the California Department of Industrial Relations (DIR), and its cover sheet is the Notice of Potential Eligibility, which explains the benefits you may receive. The employee completes the Employee section and the employer completes the Employer section. 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, Workers' compensation claim form (Vietnamese), is the California Division of Workers' Compensation (DWC) claim form, printed in English with Vietnamese translation, that an injured or ill employee completes and gives to the employer to start a workers' compensation claim.
The PDF has two parts. The cover sheet is the Notice of Potential Eligibility, which the employee detaches and keeps. It describes medical care, temporary disability (lost wages), permanent disability, the Supplemental Job Displacement Benefit (SJDB), death benefits, protection against punishment or firing under Labor Code 132a, and where to get help with problems or disputes. The claim form itself has numbered items 1 to 9 for the employee and items 10 to 19 for the employer.
The form is printed in four copies: Employer copy, Employee copy, Claims Administrator and Temporary Receipt. Signing it is not an admission of liability by the employer.
The DWC publishes this same claim form in Spanish, Chinese, Korean, Tagalog and Vietnamese. This page covers the Vietnamese edition, revision Rev. 1/1/2016. The form states that an injury or illness covered includes physical or mental harm caused by the job, including injuries resulting from a workplace crime.
Who needs to file DWC 1?
An employee who is injured or becomes ill, physically or mentally, because of the job, including from a workplace crime, uses this form to file a workers' compensation claim with the employer. The form tells the employee to complete the Employee section, keep one copy and give the rest to the employer.
The employer then completes the Employer section (items 10 to 19). The form states that the employer must date it and provide copies to the insurer or claims administrator and to the employee, dependent or representative who filed the claim.
Other people named on the form: a dependent or representative may be the person who files the claim, and the notice says death benefits may be paid to a spouse and to relatives or household members who were financially dependent on a worker who died.
You may be eligible for some or all of the benefits listed in the Notice of Potential Eligibility, depending on the nature of your claim. The form does not set an eligibility test beyond the injury or illness being caused by the job.
When to file DWC 1
Complete the Employee section right away after a job injury or illness. The notice warns that delay can cause problems with your claim and that, in some cases, benefits will not start until you inform your employer of the injury by filing a claim form. No other deadline is printed on the form.
After you file, the employer must complete the Employer section, give you a dated copy, keep one copy and send one to the claims administrator within one working day. The claims administrator must notify you within 14 days whether the claim is accepted or whether more investigation is needed. Within one working day after you file, the employer or claims administrator must also authorize treatment for your injury, consistent with the applicable treating guidelines, until the claim is accepted or rejected.
How to fill out DWC 1
Read the Notice of Potential Eligibility
The cover sheet explains the benefits you may receive and what to do after a job injury. Detach it and save it for future reference.
Enter your name and today's date
Item 1: your name and Today's Date.
Enter your home address
Item 2: your home address. Item 3: city, state and ZIP code.
Enter the date and time of injury
Item 4: Date of Injury, and the Time of Injury marked a.m. or p.m.
Give the place where the injury happened
Item 5: the address and a description of where the injury happened.
Describe the injury completely
Item 6: describe the injury and every part of the body affected.
Enter your Social Security Number
Item 7: your Social Security Number.
Choose email notices if you want them
Item 8: check the box only if you agree to receive notices about your claim by email only, and write your e-mail address. Otherwise notices come by regular mail.
Sign the Employee section
Item 9: signature of the employee. Then give the form to your employer and keep a copy marked "Employee's Temporary Receipt".
Employer: complete the employer details
Items 10 and 11: employer name and address. Items 12 to 14: the date the employer first knew of the injury, the date the claim form was provided to the employee and the date the employer received it.
Employer: add insurer details and sign
Items 15 and 16: name and address of the insurance carrier or adjusting agency, and the policy number. Items 17 to 19: signature of the employer representative, title and telephone.
Review and download the completed PDF
Check every item against the notes on the form, then download or print the completed PDF from FillingPDF. Give it to your employer as described under How to submit.
How to submit DWC 1
You file the form by giving it to your employer, in person or by mail. The form names no portal or agency address; the claim goes to the employer, who passes copies on.
- In person: complete the Employee section, keep one copy and give the rest to your employer. Mark your copy "Employee's Temporary Receipt" until you receive the signed and dated copy back from the employer.
- By mail: use first-class or certified mail. If you buy a return receipt, you can prove that the claim form was mailed and when it was delivered.
Within one working day of receiving it, the employer must complete items 10 to 19, give you a dated copy, keep a copy and send a copy to the claims administrator. For questions, you can hear recorded Division of Workers' Compensation information at (800) 736-7401, or contact a state Information & Assistance (I&A) officer through www.dwc.ca.gov. FillingPDF lets you fill out and download the PDF; submission follows the channels above.
Common mistakes to avoid
- Waiting to file: the notice says to complete the Employee section right away, and in some cases benefits do not start until you inform your employer by filing a claim form.
- Describing the injury incompletely; the form says to describe it fully and include every part of the body affected (item 6).
- Giving the employer every page without keeping a copy; the form tells you to keep one copy and mark it "Employee's Temporary Receipt".
- Mailing the form by a method that leaves no proof; the notice says to use first-class or certified mail and that a return receipt proves the mailing and delivery date.
- Checking the email-only box in item 8 without writing your e-mail address; without a choice or an electronic option, notices come by regular mail.
- Leaving the Employer section undated or unsigned; the employer must date the form and give copies to the claims administrator and the employee within one working day.
- Making a knowingly false or fraudulent material statement on the form, which the form says is a felony.
- Not telling the employer in writing if you later want notices by mail after agreeing to email-only notices.
Frequently asked questions
What is the DWC-1 form in Vietnamese?
It is the California Division of Workers' Compensation claim form (DWC 1) in a Vietnamese edition, Rev. 1/1/2016. An employee who is hurt or made ill by the job completes it and gives it to the employer. Its cover sheet is the Notice of Potential Eligibility.
Who fills out Form DWC 1?
The employee completes items 1 to 9 (the Employee section) and the employer completes items 10 to 19 (the Employer section). The employer must date the form and send copies to the claims administrator and to the person who filed the claim within one working day.
Where do I send the DWC 1 claim form?
To your employer, not to the DWC. Give it to the employer in person or mail it first-class or certified; a return receipt lets you prove when it was delivered. Keep one copy marked "Employee's Temporary Receipt" until you get the signed, dated copy back.
How long does the employer have to complete its part?
One working day after receiving the form. The employer must complete the Employer section, give you a dated copy, keep one and send one to the claims administrator. The claims administrator then has 14 days to tell you whether the claim is accepted or needs more investigation.
Can I fill out the Vietnamese DWC 1 online?
You can fill out the PDF online on FillingPDF and download or print it. FillingPDF is an independent service and does not submit the claim; you give or mail the completed form to your employer.
Is there a deadline to file a DWC 1 claim form?
The form prints no date, but it says to file right away to avoid problems with your claim. In some cases benefits will not start until you tell your employer about the injury by filing a claim form.
Can my employer punish me for filing a workers' compensation claim?
No. The notice says it is illegal for an employer to punish or fire you for a job injury or illness, for filing a claim or for testifying in another person's case (Labor Code 132a). If proven, you may receive lost wages, reinstatement, increased benefits, and costs and expenses up to state limits.
Does the DWC publish the claim form in other languages?
Yes. The DWC forms page lists the DWC 1 workers' compensation claim form in Spanish, Chinese, Korean, Tagalog and Vietnamese. This page covers the Vietnamese edition.
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