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  • State Of Californiaform Ad 10133 57

Get State Of Californiaform Ad 10133 57

57 Injured Employee (To Be Completed By The Employer or Claims Administrator) (All information in this section must be completed) First Name MI Last Name Address/PO Box (Please leave blank spaces between numbers, names or words) City State Zip Code Date of Birth: MM/DD/YYYY Claim Number Phone Claims Administrator (To Be Completed By The Employer or Claims Administrator) (All information in this section must be completed) Name (Please leave blank spaces between numbers, names or words).

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The Form CA-1 was developed to ensure regulatory compliance and to be more customer friendly. The form must be completed by the injured employee, a witness, and the injured employee's supervisor.

The Division of Workers' Compensation (DWC) monitors the administration of workers' compensation claims, and provides administrative and judicial services to assist in resolving disputes that arise in connection with claims for workers' compensation benefits.

On the form, you will need to only fill out the “Employee” section, which asks for basic information: Name, date, and address. Date and location of injury. Brief description of injury. List of injured body parts. Social Security Number.

Division of Workers' Compensation (DWC): A division within the state Department of Industrial Relations (DIR).

Workers' Compensation Claim Form (DWC-1) Form DWC-1 is used to file a workers' compensation claim with your employer.

“Regular work” means the employee's usual occupation or the position in which the employee was engaged at the time of injury and that offers wages and compensation equivalent to those paid to the employee at the time of injury, and located within a reasonable commuting distance of the employee's residence at the time ...

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232