The Korean version of the DWC 1, the Workers’ Compensation Claim Form (DWC 1) & Notice of Potential Eligibility, is the bilingual English and Korean claim form published by the California Division of Workers’ Compensation (DWC). An employee who is hurt or becomes ill because of the job uses it to file a claim with the employer; it is the same DWC-1 form that DWC publishes in other languages. On FillingPDF you can fill out the form online and download or print the completed PDF. The official PDF and the DWC forms page are at the agency.
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What is DWC 1?
The Workers’ Compensation Claim Form (DWC 1) & Notice of Potential Eligibility is the State of California form an employee completes to file a workers’ compensation claim with the employer after a job-related injury or illness, physical or mental. This Korean version prints each line in English and in Korean.
The document has two parts. The first three pages are the Notice of Potential Eligibility, the cover sheet that explains the benefits an injured worker may be eligible for: medical care, temporary disability, permanent disability, the Supplemental Job Displacement Benefit (SJDB) and death benefits. It also explains how to change doctors, how disputes are resolved and where to get help. The agency tells you to keep this notice for your records. The second part is the claim form itself, with an Employee section (lines 1 to 9) and an Employer section (lines 10 to 19).
The form is issued by the Division of Workers’ Compensation (DWC) of the Department of Industrial Relations (DIR). The DWC forms page lists the same DWC 1 in Spanish, Chinese, Korean, Tagalog and Vietnamese. The form is printed in four copies: Employer, Employee, Claims Administrator and Temporary Receipt. Once the claim is filed, the claims administrator, who handles the claim, must tell you within 14 days whether it is accepted or needs more investigation.
Who needs to file DWC 1?
An employee who is injured or becomes ill, physically or mentally, because of the job, including an injury resulting from a workplace crime, uses this form to file a workers’ compensation claim with the employer. The Notice of Potential Eligibility says you may be eligible for some or all of the listed benefits, depending on the nature of the claim.
Other people complete or receive parts of the form:
- Employers complete the Employer section (lines 10 to 19). They must date the form and provide copies to the insurer or claims administrator and to the employee, dependent or representative who filed the claim, within one working day of receiving the form from the employee.
- A dependent or representative of the employee may be the person who files the claim, as the employer instructions refer to a "dependent or representative who filed the claim".
- Claims administrators receive a copy and handle the claim.
Korean readers can use this version because every line has a Korean label. The form does not say that the Korean text replaces the English text.
When to file DWC 1
File the claim right away after a work injury or illness. The Notice of Potential Eligibility says to complete the Employee section and give the form to your employer immediately to avoid problems with your claim, and that in some cases benefits do not start until you tell your employer about the injury by filing a claim form. The form prints no calendar deadline.
After you file, the employer has one working day to complete the Employer section, give you a dated copy, keep one copy and send one to the claims administrator. The claims administrator must then notify you within 14 days whether the claim is accepted or whether further investigation is needed. Until you receive the signed and dated copy from your employer, keep your own copy marked "Employee’s Temporary Receipt".
How to fill out DWC 1
Read the Notice of Potential Eligibility
Read the three-page cover sheet before filling in the claim form, and keep it with your records. It explains your possible benefits, the doctor rules and where to get help.
Enter your name and today’s date
On line 1, write your name and today’s date. Line 2 asks for your home address.
Add city, state and ZIP code
On line 3, enter your City, State and Zip.
Record the date, time and place
On line 4, enter the date of injury and the time of injury, marking a.m. or p.m. On line 5, give the address and a description of where the injury happened.
Describe the injury fully
On line 6, describe the injury and every part of your body affected. Give the complete picture, since the notice asks you to include all affected body parts.
Enter your Social Security number
On line 7, write your Social Security Number.
Choose email-only notices if you want them
On line 8, check the box only if you agree to receive notices about your claim by email only, and enter your email. If you do not choose, or the claims administrator offers no electronic option, notices come by regular mail.
Sign the employee line
Sign line 9, Signature of employee. Keep one copy, marked "Employee’s Temporary Receipt", and give the rest to your employer.
Have the employer complete lines 10 to 19
The employer enters its name and address, the date it first knew of the injury, the date the claim form was provided to you and the date it received the form. It also adds the insurance carrier or adjusting agency, policy number, representative signature, title and telephone.
Review and download the completed PDF
Check that each line is filled and signed, then download or print the completed PDF from FillingPDF. Keep your copy and deliver the form to your employer as described under How to submit.
How to submit DWC 1
You give the completed DWC 1 to your employer; the form is not mailed to the Division of Workers’ Compensation. The two ways it names are handing it over or mailing it.
- Hand delivery to the employer: complete the Employee section (lines 1 to 9), 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.
- Mail to the employer: 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 the employer completes the Employer section, gives you a dated copy, keeps one copy and sends one to the claims administrator.
For questions you can call the Division of Workers’ Compensation at (800) 736-7401 for recorded information and a list of local Information & Assistance offices, or go to 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 and give the form to your employer right away, and some benefits do not start until your employer is informed through a claim form.
- Describing the injury incompletely on line 6; the notice says to describe it fully and include every part of the body affected.
- Giving the employer the original without keeping a copy; you should keep one copy marked "Employee’s Temporary Receipt" until you get the signed and dated copy back.
- Mailing the form by ordinary mail instead of first-class or certified mail, or skipping a return receipt, which is what proves the mailing and delivery date.
- Checking the email-only box on line 8 without entering your email on the "Employee’s e-mail" line; without a valid choice you receive notices by regular mail.
- Leaving line 9, the employee signature, blank.
- Making any knowingly false or fraudulent material statement on the form; the form states this is a felony.
- Employers failing to date the form and provide copies within one working day of receiving it from the employee.
Frequently asked questions
What is the DWC-1 form in Korean?
It is the Korean-English version of the California Workers’ Compensation Claim Form (DWC 1) & Notice of Potential Eligibility, published by the Division of Workers’ Compensation. An employee uses it to file a claim with the employer after a work injury or illness.
Who fills out the DWC 1 claim form?
The employee completes the Employee section (lines 1 to 9) and gives the form to the employer. The employer then completes the Employer section (lines 10 to 19), dates the form and distributes the copies.
Where do I submit the DWC 1 form?
To your employer, not to the state. Hand it over or mail it using first-class or certified mail; a return receipt proves when it was delivered. The employer sends a copy to the claims administrator.
How long does the employer have after I file the claim?
One working day. The employer must complete the Employer 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.
Is there a deadline to file the DWC 1?
The form prints no calendar deadline, but it says to file right away. In some cases benefits do not start until you inform your employer of the injury by filing a claim form, so delay can cause problems with your claim.
Can I fill out the Korean 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 file the claim; you give the form to your employer yourself.
Is the DWC 1 available in other languages?
Yes. The Division of Workers’ Compensation forms page lists the workers’ compensation claim form DWC 1 in Spanish, Chinese, Korean, Tagalog and Vietnamese.
Does the employer admit liability by signing the DWC 1?
No. The employer section states that signing the form is not an admission of liability. The employer signs to confirm it received the claim form, with the required dates and copies.
Can my email be used for claim notices?
Yes, if the claims administrator offers it. On line 8, check the box to agree to receive notices by email only and enter your email. If you later want mail, you must tell your employer in writing.
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