Get State Of California Division Of Workers ...

Completing the STATE OF CALIFORNIA DIVISION OF WORKERS' COMPENSATION form online is a critical step for workers seeking benefits. This guide will provide you with clear, step-by-step instructions to help you navigate the form with ease.

Follow the steps to successfully complete your form online.

1. Press the ‘Get Form’ button to access the form and open it in your preferred online editor.
2. Enter the date of injury in the specified format (MM/DD/YYYY). Make sure the date is accurate to ensure proper processing of your claim.
3. Fill in your case number. This number is essential for identifying your claim in the system.
4. Provide your social security number using numbers only. This information is required for identification purposes.
5. Choose the venue based on your residence, location of injury, or attorney's address. This choice determines where your hearing will take place.
6. Select the appropriate three-letter office code for the place or venue of the hearing from the provided document cover sheet.
7. Complete the applicant section, including your middle initial, first name, last name, and address. Be sure to leave appropriate spaces between each part of your address.
8. Enter the required employer information for each employer listed in the form. Ensure accuracy in their names and addresses to avoid issues.
9. Provide insurance carrier information, if applicable. Fill in the name and address of the insurance carrier associated with your claim.
10. Enter details about the injury, including specific or cumulative injury classifications and the body parts affected. Include the relevant dates.
11. Fill out the indemnity information regarding temporary and permanent disability, noting the amounts paid and periods covered.
12. Complete the attorney fee requests, liens, and any other stipulations required by the form. Make sure all amounts are clear and accurate.
13. Sign and date the form as the applicant and have your attorney sign as well, if applicable. Ensure both signatures are included for processing.
14. Finally, save your changes, download a copy for your records, and prepare to print or share the completed form as necessary.

Complete your form online to ensure your claim is processed smoothly and efficiently.