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Acme Manufacturing

DWC-1 — ZZ Wizard Flow Test (delete me)

Print the DWC-1 ▸◂ Back to the claim

Client Admin ▸ Safety ▸ Claims ▸ Claim form ▸ Case 4 · 2026 · Amarillo Yard

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

This workflow records dates and surfaces the duties that attach to them. It does not decide, accept or deny a claim, does not authorise treatment, and does not file anything on your behalf. It is not legal advice — confirm your obligations with counsel or your claims administrator.

Filed with the carrierSent to the insurer or claims administrator.Next: Nothing outstanding here — the carrier's 90-day decision runs next

Queues another copy and records it. The original provided-to-employee date is not changed — that duty was discharged the first time.

Employee section — completed and signed by the employee — read-only here

Name
ZZ Wizard Flow Test (delete me)
Address
418 Oak Street, Amarillo, TX 79101
Social security number
•••-••-6789
Date of injury
2026-06-10
Time of injury
about 10:15am
Where it happened
Amarillo Yard, receiving bay
Injury or illness, and parts of the body affected
Cut to the base of my left thumb from a box cutter while opening cartons
Employee signature
ZZ Wizard Flow Test · signed 2026-09-18

Employer section — completed and signed by the employer

Employer legal name
Acme Manufacturing
Employer address
1200 Harbor Blvd, Suite 400, Oakland, CA 94607
Insurer or claims administrator
State Fund
Policy number
WC-0042118-26
Employer signature
Dana Whitfield · HR Manager · signed 2026-09-18

Date of knowledge — the one date both statutory windows below are measured from

Date the employer first knew

2026-06-11

Both windows on this form are measured from it — Labor Code 5401(a) and 5402(b).

Entered by hand. This claim has no field incident report behind it — the case was recorded directly, which is the ordinary path for a walk-in injury reported straight to HR.

Where the clocks stand — target windows, adjustable in one place

  • Give the employee the claim formDone 2026-09-18
  • Employee returns the completed formDone 2026-09-18internal target
  • Forward a dated copy to the carrier and the employeeDone 2026-09-18

Working days are counted Monday to Friday. Public holidays are not subtracted — California’s list changes and employers observe different ones, so a wrong calendar would silently move a statutory deadline. Counting only weekends errs tight, never loose. The employee-return window is an internal follow-up target of 10 days, not a legal deadline; the two one-working-day windows are statutory.

Timeline — every step, with who and when — append-only

  1. Form startedDraft18 Sep 2026 · 01:02 UTC
    client-admin · date of knowledge 2026-06-11
  2. Provided to the employeeWith the employee18 Sep 2026 · 01:05 UTC
    client-admin · queued — no email address on file
  3. Employee completed and signedReturned by the employee18 Sep 2026 · 01:06 UTC
    employee-token:ZZ Wizard Flow Test (delete me) · signed by ZZ Wizard Flow Test
  4. Employer completed and signedEmployer section complete18 Sep 2026 · 01:08 UTC
    client-admin · signed by Dana Whitfield · completed form received 2026-09-18
  5. Filed with the carrierFiled with the carrier18 Sep 2026 · 04:06 UTC
    client-admin · to State Fund · 0 working days after receipt

Read from the audit log rather than from the form’s own columns: the columns hold the current value of each stamp, the log holds what actually happened, in order, and cannot be edited or deleted by anyone.

What follows from here
90-day presumption of compensability — day 50 of 90, counting from 2026-09-18, the date the employer received the completed form. 40 days remain, to 2026-12-17. If the claim is not rejected within that window it is presumed compensable (Labor Code 5402(b)). The carrier decides — this counts the days.
Give the employee the form within one working day — Labor Code 5401(a): once the employer knows of an injury needing more than first aid, the claim form goes to the employee within one working day.
Forward a dated copy within one working day of receiving it back — Labor Code 5401(c): when the completed form comes back, a dated copy goes to the claims administrator AND a dated copy goes back to the employee, within one working day. Recorded as sent on 2026-09-18.
Authorise up to $10,000 of treatment while investigating — Labor Code 5402(c): from the date the completed form is received, treatment is authorised up to $10,000 until the claim is accepted or rejected. The employer and carrier act on this; the software only reminds. Running from 2026-09-18. This app does not authorise treatment or track spend against that limit.

These are reminders of the employer’s and the carrier’s duties, with the dates they run from. Nothing here is performed automatically, and none of it is legal advice.

Test data only. PII_ENCRYPTION_KEY is not set, so the stored number is encrypted with a key derived from the source. That is fine for test data and is not protection for a real social security number.

Every step is recorded with who did it and when · the form is retained, never deleted