DWC-1 — printable
Client Admin ▸ Safety ▸ Claims ▸ DWC-1
This reproduces the captured data in the official form’s shape. The canonical form is the California Division of Workers' Compensation’s own; use this for your records and your filing, and check it against the state’s current version.
Employee: Complete the “Employee” section and give the form to your employer. Keep a copy. You may be entitled to workers’ compensation benefits. Employer: Complete the “Employer” section and give a dated copy to the employee and to your claims administrator.
1. Name of employee ZZ Broker Alert Test (delete me) | 2. Date of injury 2026-09-15 | 3. Time of injury |
4. Address where injury happened | 5. Home address | 6. Social security number Not provided (optional) |
7. Describe injury or illness and part of body affected Twisted right ankle | ||
8. Signature of employee ZZ Broker Alert Test | 9. Date signed 2026-09-18 | Signature type Electronic — typed name, recorded 21:15 UTC |
Employee declaration: “I declare that the information I have given on this form is true and correct to the best of my knowledge.”
10. Name of employer Acme Manufacturing | 11. Address | |
12. Date employer first knew of injury 2026-09-15 | 13. Date claim form was provided to employee 2026-09-18 | 14. Date employer received claim form 2026-09-18 |
15. Name and address of insurance carrier or claims administrator State Fund | 16. Policy number | 17. Date filed with carrier 2026-09-18 |
18. Signature of employer representative Dana Whitfield | 19. Title HR Manager | 20. Date signed 2026-09-18 |
Employer certification: “I certify that the employer section of this form is complete and correct to the best of my knowledge, and that a dated copy will be provided to the employee and to the claims administrator.”
You may be entitled to workers’ compensation benefits for a work-related injury or illness. Within one working day of receiving this completed form, your employer must give you a dated copy and send a dated copy to the claims administrator (Labor Code 5401(c)).
From the date the employer receives this completed form, up to $1,000,000 in medical treatment must be authorised while the claim is investigated (Labor Code 5402(c)), and if the claim is not rejected within 90 days of that date it is presumed compensable (Labor Code 5402(b)).
Reproduced by the EHM safety module from the data captured for case 6 · 2026 · Amarillo Yard. The canonical form is the California Division of Workers' Compensation’s own.