DWC form walkthrough

Application for Adjudication of Claim, explained

By the CalCompGuide editorial team · Last updated November 2026 · How we write and check guides

When you need it

• Your claim was denied, or not decided and benefits aren't being paid.
• You need a hearing on temporary disability, treatment or another dispute.
• You're approaching the one-year deadline with benefits disputed.
• A settlement needs a case to be approved in (the parties often file it then).

What the form asks

• Your name, address and the last digits of your Social Security number.
• The employer's legal name and address, and the insurer or claims administrator. If the employer is uninsured, the Uninsured Employers Benefits Trust Fund is named too.
• Date(s) of injury, specific or cumulative, and body parts.
• Your occupation and earnings, and benefits received.
• The issues in dispute (for example compensability, TD, medical treatment, PD).

How to file

Attorneys file electronically through the DWC's case system. If you don't have an attorney, you can file paper forms with a document cover sheet and separator sheet at the district office that serves you (find it by ZIP code), and you must serve copies on the other parties. The DWC's step-by-step I&A guide 4 walks through it, and I&A officers can help in person.

After filing

You receive an ADJ case number. To get a hearing date, a party files a Declaration of Readiness to Proceed. See what happens at the WCAB and our list of WCAB district offices.

We link to the official form on dir.ca.gov rather than hosting a copy, so you always get the current version.