Your workers’ compensation claim form

DWC-1 · Acme Manufacturing · injury recorded 2026-09-21

Your employer has started this form for you. Some of it is filled in already from what they recorded — check it and change anything that is not right, then sign at the bottom. This is your account of what happened.

Your name

Your home address

Date of injury

Time of injury

An approximate time is fine. Say what you remember.

Where it happenedWhat happened, and which parts of your body were hurt

In your own words. Name every part of your body that was affected, even if it seemed minor at the time.

Social security number (optional)

You do not have to give this. The form can be submitted and your claim handled without it. If you do give it, only the last four digits are ever shown on screen, the full number is encrypted, and it is never visible to anyone outside your employer.

Your signature

I declare that the information I have given on this form is true and correct to the best of my knowledge.

I have read the declaration above and agree to it.Type your full name to sign

Typing your name here is your signature, and the date and time are recorded with it.

Once you submit this, your employer completes their section and sends a dated copy to the insurance company and back to you. You cannot edit this form afterwards — if something needs correcting, tell your employer.

Workers' Compensation Claim Form (DWC 1) & Notice of Potential Eligibility
California Division of Workers' Compensation · California Labor Code §§ 5401–5402