Get Dwc 12

Filling out the Dwc 12 form is an essential step in the process of submitting a notice of denial related to workers’ compensation benefits. This guide provides comprehensive, step-by-step instructions to help users accurately complete this form online.

Follow the steps to complete the Dwc 12 form correctly.

1. Click ‘Get Form’ button to obtain the Dwc 12 form and open it in the editing environment.
2. Begin by filling in the 'Date' and 'Received Date' fields at the top of the form. Ensure the dates are accurately formatted as Month-Day-Year.
3. In the 'Employee Name' section, provide the full name of the employee, including the first, middle, and last name. Use clear, legible typing or printing.
4. Enter the employee's address in the designated field, ensuring that you include all necessary details such as street, city, state, and ZIP code.
5. Fill in the 'Employer Name' section with the complete name of the employer involved in the claim.
6. Indicate the 'Date of Accident' in the appropriate field, ensuring that it reflects the actual date of the incident as Month-Day-Year.
7. List any denied benefits in the section titled 'Denied Benefits' below. Provide as much detail as necessary.
8. Explain the 'Reason for Denial of Benefits' by providing detailed information that supports the groups of denial listed above in a clear manner.
9. If applicable, indicate the 'Date Denial Rescinded' in the designated format (MM/DD/YYYY) and provide a description of which benefits have been reinstated.
10. Complete the areas for 'CC' (Name and Address), 'Adjuster Name', and 'Adjuster Telephone', making sure that all contact information is accurate.
11. Fill in the 'Insurer Code', 'Insurer Name', 'Claims-Handing Entity Name and Address' along with the corresponding 'Claims-Handling Entity File #' on the document.
12. Review all entered information for accuracy before moving to the next step.
13. Once completed, save changes to the form. You can then download, print, or share the form as needed.

Start completing your documents online today!