EHM Academy
AM

Acme Manufacturing

DWC-1 — Dana Ruiz

Print the DWC-1 ▸◂ Back to the claim

Client Admin ▸ Safety ▸ Claims ▸ Claim form ▸ Case 9 · 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.

With the employeeProvided to the employee, who completes and signs their section.Next: Waiting on the employee's section

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

Test mode — stand-in for the employee’s email. Email sending and employee logins are not built yet, so the message above was recorded rather than sent. Open the employee’s own view to walk the rest of the workflow:Open employee view (test) ▸This is the real per-form link, not a simulation — when email arrives it is this URL that gets sent, and this box goes away.

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

Name
Dana Ruiz
Address
Not yet given
Social security number
Not given (optional)
Date of injury
2026-09-21
Time of injury
Not yet given
Where it happened
North stairwell, 3rd floor
Injury or illness, and parts of the body affected
Slipped on wet decking coming down the stairs and landed on his left wrist.
Employee signature
Not signed yet

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
Not signed yet

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

Date the employer first knew

2026-09-21

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

Prefilled from the field report. Field incident report #P4ZPV3, reported 9/21/2026, 11:26:00 PM. That stamp records the same event this date describes — the moment the news reached the employer — so the report and this form anchor on one timestamp rather than two that can disagree.

The date of knowledge is the employer's determination. The field report's timestamp is offered as the starting point because it records the same event — it is never locked, and moving it is a normal thing to do.

Where the clocks stand — 1 window needing attention

  • Give the employee the claim formDone 2026-09-21
  • Employee returns the completed formOverdue47 days elapsed, target 10internal target
  • Forward a dated copy to the carrier and the employeenot started

Anchored on the field report. This window is anchored on the timestamp captured when the field report was filed — the same moment the employer learned of the injury, recorded once and used by both records.

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 startedDraft21 Sep 2026 · 23:57 UTC
    EHM super-admin on behalf of Acme Manufacturing · date of knowledge 2026-09-21
  2. Date of knowledge corrected21 Sep 2026 · 23:57 UTC
    EHM super-admin on behalf of Acme Manufacturing · 2026-09-21 → 2026-09-19 · The site supervisor was told two evenings before the report was filed.
  3. Date of knowledge corrected21 Sep 2026 · 23:57 UTC
    EHM super-admin on behalf of Acme Manufacturing · 2026-09-19 → 2026-09-21
  4. Provided to the employeeWith the employee21 Sep 2026 · 23:57 UTC
    EHM super-admin on behalf of Acme Manufacturing · queued to d.ruiz@acme-mfg.com

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.

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