The Tagalog version of the Workers’ Compensation Claim Form (DWC 1) & Notice of Potential Eligibility is the claim form that the California Division of Workers’ Compensation (DWC), part of the Department of Industrial Relations (DIR), publishes with English and Tagalog text side by side. It is the DWC-1 form an injured or ill employee completes and gives to the employer to file a workers’ compensation claim. On this page you can fill out the form online on FillingPDF and download or print the completed PDF; the original PDF is published by the DWC at dir.ca.gov.
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What is DWC 1?
The Workers’ Compensation Claim Form (DWC 1) & Notice of Potential Eligibility is the California form an employee uses to file a workers’ compensation claim with the employer for an injury or illness, physical or mental, caused by the job. This page covers the Tagalog version, which prints English and Tagalog together.
The document has two parts. The first three pages are the Notice of Potential Eligibility, the cover sheet that explains the benefits you may be eligible for: medical care, temporary disability, permanent disability, the Supplemental Job Displacement Benefit (SJDB) and death benefits. It also covers choosing and switching doctors, disclosure of medical records, resolving disputes and where to get help from an Information & Assistance (I&A) officer of the DWC. The form says to detach and keep this notice.
The second part is the claim form itself, with an Employee section (items 1 to 9) and an Employer section (items 10 to 19). It is printed as four copies: Employer, Employee, Claims Administrator and Temporary Receipt.
The DWC publishes the same claim form in Spanish, Chinese, Korean and Vietnamese as well as Tagalog. Signing the form is not an admission of liability by the employer.
Who needs to file DWC 1?
An employee who is injured or becomes ill, physically or mentally, because of the job uses this form to file a workers’ compensation claim with the employer. The notice says this includes injuries resulting from a workplace crime.
- The employee completes the Employee section (items 1 to 9), keeps one copy and gives the rest to the employer.
- A dependent or representative may be the person who files the claim: the employer’s note on the form refers to the employee, dependent or representative who filed it, and the employer must give that person a copy.
- The employer completes the Employer section (items 10 to 19). The employee does not fill it in.
- The claims administrator, who handles the claim, receives a copy from the employer.
Reading the Tagalog text is optional help; the English and Tagalog sides carry the same content. The form does not list any group excluded from filing.
When to file DWC 1
File the claim form right away after a job injury or illness. The notice says to do this promptly to avoid problems with your claim, and that in some cases benefits will not start until you inform your employer of the injury by filing the claim form. The form prints no calendar deadline.
After you file, the clock runs on the other side. Within one working day, your employer must complete the Employer section, give you a dated copy, keep one copy and send one to the claims administrator. The employer must date the form and distribute copies within one working day of receiving it from you. The claims administrator must then tell you within 14 days whether your claim is accepted or needs more investigation.
How to fill out DWC 1
Read the Notice of Potential Eligibility
Read the cover pages first. They explain the benefits, doctor choice and dispute steps, and the form tells you to detach and keep them.
Enter your name and today’s date
Item 1: write your name and today’s date (Petsa Ngayon).
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: the date of injury, the time of injury and check a.m. or p.m.
Describe where the injury happened
Item 5: give the address and a description of the place where the injury happened.
Describe the injury completely
Item 6: describe the injury and the part of the body affected. Include every part of your body that the injury affected.
Enter your Social Security Number
Item 7: your Social Security Number.
Choose how you receive notices
Item 8: check the box only if you agree to receive claim notices by email only, and enter your email. Without a choice, or if your claims administrator offers no electronic option, notices come by regular mail.
Sign the Employee section
Item 9: sign as the employee. Leave items 10 to 19 for your employer to complete.
Review, download and give to employer
Check every entry, then download or print the completed PDF from FillingPDF. Keep one copy marked “Employee’s Temporary Receipt” and give the rest to your employer as described under How to submit.
How to submit DWC 1
You file the DWC 1 with your employer, by handing it over or by mailing it. The form names no agency address or portal for the employee to use.
- In person 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 you receive the signed and dated copy back.
- By mail to your employer: use first-class or certified mail. A return receipt lets you prove the claim form was mailed and when it was delivered.
Your employer completes its section, returns a dated copy to you and sends a copy to the claims administrator within the one-working-day period. If you choose to receive claim notices by email only (item 8), give your email address on the form; otherwise notices come by regular mail.
For forms and help, an I&A officer of the DWC can be reached through the recorded line at (800) 736-7401. FillingPDF lets you fill out and download the PDF; submission follows the channels above.
Common mistakes to avoid
- Waiting to file the claim form; the notice says that in some cases benefits do not start until you inform your employer of the injury by filing it.
- Describing the injury briefly in item 6 instead of completely; the instructions say to include every part of the body affected.
- Mailing the form by ordinary mail with no proof; the form says to use first-class or certified mail, and a return receipt proves mailing and delivery.
- Giving away every copy and keeping none, or not marking your copy “Employee’s Temporary Receipt” until the signed and dated copy comes back.
- Filling in the Employer section (items 10 to 19) yourself; the employer completes it.
- Checking the email-only box in item 8 without meaning to; to return to mailed notices you must inform your employer in writing.
- Making a knowingly false or fraudulent material statement on the form; the form states this is a felony.
- Throwing away the Notice of Potential Eligibility; the form tells you to detach and save it for future reference.
- Employer side: not dating the form and giving copies to the insurer or claims administrator and to the employee within one working day.
Frequently asked questions
What is the DWC-1 form?
The DWC-1 form is California’s Workers’ Compensation Claim Form (DWC 1), which an employee completes and gives to the employer to claim benefits for a job-related injury or illness. This Tagalog version prints English and Tagalog together and includes the Notice of Potential Eligibility as its cover sheet.
Is the DWC 1 claim form available in languages other than Tagalog?
Yes. The Division of Workers’ Compensation forms page lists the DWC 1 claim form in Spanish, Chinese, Korean, Tagalog and Vietnamese. This page covers the Tagalog version, Rev. 1/1/2016, which carries the same items 1 to 19 as the other versions.
Who fills out the DWC-1 claim form?
The employee completes the Employee section (items 1 to 9) and the employer completes the Employer section (items 10 to 19). The form also refers to a dependent or representative who files the claim, and the employer must give that person a copy.
Where do I send the DWC 1 form?
Give it to your employer. If you mail it, use first-class or certified mail, and consider a return receipt to prove when it was delivered. The form gives no agency address for employees; your employer sends a copy to the claims administrator.
How long does the employer have to act on my claim form?
Within one working day after you file, your employer must complete its section, give you a dated copy, keep one and send one to the claims administrator. The claims administrator must then notify you within 14 days whether the claim is accepted or needs further investigation.
Does my employer admit fault by signing the DWC 1?
No. The form states that signing it is not an admission of liability. The employer must date the form and give copies to its insurer or claims administrator and to the person who filed the claim within one working day of receiving it.
Can I get claim notices by email instead of mail?
Yes, if your claims administrator offers electronic notices. Check the box in item 8 and write your email address. Notices then come by email only; to go back to mail, tell your employer in writing.
Can I fill out the DWC-1 form online on FillingPDF?
You can fill out the fillable PDF online on FillingPDF and download or print it. FillingPDF is an independent service, not the DWC, and does not file the claim: you give or mail the completed form to your employer.
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