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Ling form in detail to file for reimbursement of services. For Supplies & Equipment - Complete sections 1, 3 & 4For Drug Products - Complete sections 1, 2 & 4 SECTION I 1. EMPLOYEE'S NAME (FIRST, MIDDLE, LAST) 3. DATE OF ACCIDENT 2. EMPLOYEE'S SOCIAL SECURITY # OR DIVISION ASSIGNED # 4. EMPLOYEE'S DOB 5. GENDER MALE 7. INSURER/CARRIER NAME & ADDRESS SECTION 2 PRESCRIPTION DRUGS 9a. NDC NUMBER PRIMARY (5 4 2 format) 10. QUANTITY 6. CLAIMS-HANDLING ENTITY INTERNAL FILE # FEMALE 11. DAYS 8.

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“For information about the workers' compensation claims process and your rights and obligations, go to .dwc.ca.gov or contact an Information and Assistance (I&A) officer of the state Division of Workers' Compensation. For recorded information and a list of offices, call toll-free 1-800-736-7401.”

A workers' comp claim can show up on a background check but your new employer can only see your workers' comp record after they've sent a conditional job offer. Unlike some states, in California, your record is off-limits to everyone except you, the court, and your former employer.

To find out which insurer provides workers' compensation insurance for a specific employer, contact the Workers' Compensation Insurance Rating Bureau (WCIRB). The roster of self-insured employers can be found on the Self Insurance Plans Web page.

DWC-1 Workers Compensation Claim Form. This is the form you will complete and send to EMPLOYERS to initiate the claim process for your employee. This form must be completed and provided to EMPLOYERS within one working day from you becoming aware of a work-related injury or occupational disease.

DWC1 First Report of Injury (FROI). As soon as you have been notified of a work-related injury, please fill out this form and submit it to EMPLOYERS. This form must be completed within 10 days from notice of a work-related injury. Fatalities must be reported within 24 hours.

California Workers' Compensation Insurance Forms CA 130 Workers' Compensation Application. ... California Employer Fact Sheet for Employers. ... California Application for Exclusion of Officers and Stockholders. ... CA Affidavit of Exemption for Workers' Compensation Insurance. ... CA First Report of Injury Form.

(a) All claim files shall be kept and maintained for a period of five years from the date of injury or from the date on which the last provision of compensation benefits occurred as defined in Labor Code Section 3207, whichever is later.

Pursuant to Labor Code 5705, "The burden of proof rests upon the party or lien claimant holding the affirmative of the issue." The applicant has the affirmative on proving injury arising out of employment and in the course of employment (AOE/COE).

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
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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
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
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