Follow the steps to complete the form online:

1. Click 'Get Form' button to access the form and open it for editing.
2. Enter the date of injury in the MM/DD/YYYY format.
3. Fill in the case number and your Social Security Number (SSN) using numbers only.
4. Select the venue choice based on the employee’s county of residence, the county where the injury occurred, or the county of the attorney's principal place of business.
5. Choose the 3-letter office code for the place or venue of the hearing from the document cover sheet.
6. Complete the applicant’s information by providing their first name, last name, middle initial, address, city, state, and zip code.
7. For employer #1, select one of the options: insured, self-insured, legally uninsured, or uninsured. Then fill in the employer's name and address details.
8. If known, include insurance carrier information such as name and address.
9. Repeat the information entry for employer #2, employer #3, and employer #4, filling in all relevant details consistently.
10. Detail the stipulations regarding the employee’s job, occupation, and any specific or cumulative injuries on the form.
11. Document the periods of temporary disability and the amount of indemnity paid.
12. Provide information about permanent disability, medical-legal expenses, and any attorney fees.
13. Sign and date the form indicating the applicant's and attorney's agreement.
14. Once all information is entered, save the form, and you have options to download, print, or share it as needed.

Complete your CA DWC-WCAB Form 10214 (a) online today to streamline your workers' compensation process.