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DWC form walkthrough

DWC-1 claim form: a field-by-field walkthrough

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

Short answer

The DWC-1 is the form that opens a California workers' comp claim. You fill in items 1–9 (the employee section), give it to your employer, and keep a copy. Your employer completes items 10–19 and must give you a dated copy and send it to its insurer within one working day. Get the official form from the DIR website (PDF); it's bilingual English/Spanish and also available in Chinese, Korean, Tagalog and Vietnamese on the DWC forms page.

Employee section, item by item

ItemWhat to write
1. Name; Today's dateYour full legal name and the date you fill out the form.
2–3. Home addressWhere you get mail. Letters about your benefits go here, so keep it current.
4. Date and time of injuryThe date of the accident. For a gradual injury, the date you first knew it was caused by work; you can write "cumulative, through [last date worked]."
5. Where the injury happenedThe address and the specific spot (for example "loading dock, 1200 Main St.").
6. Injury and body partsDescribe what happened and list every body part affected, even ones that hurt less (for example "lifting boxes, low back and right shoulder; numbness in right hand").
7. Social Security numberUsed to identify your claim. If you don't have one, you can leave it blank; the claim is still valid.
8. Email noticesCheck only if you agree to receive notices about your claim by email only. Otherwise notices come by mail.
9. SignatureSign it. The form warns that knowingly false statements to obtain or deny benefits are a felony.

Employer section (items 10–19)

Your employer fills in its name and address, the date it first knew of the injury, the date it gave you the form and the date it received it back, the insurer or claims administrator's name and address, the policy number, and a signature, title and phone number. Check that the dates are correct on the copy you get back; they matter for your deadlines.

How to turn it in

  • Hand it to your supervisor or HR and ask for a dated copy, or
  • Mail it by first-class or certified mail with a return receipt, which proves when it arrived.
  • Until you get the signed copy back, keep yours marked "Employee's Temporary Receipt."

What filing the DWC-1 starts

  • Up to $10,000 of medical treatment must be authorized within one working day while the claim is decided (LC §5402(c)).
  • Within 14 days you should get a written notice saying the claim is accepted, denied or delayed.
  • The insurer has 90 days to accept or deny (LC §5402(b)).

Next: the full claim-filing guide and the Notice of Potential Eligibility that comes with the form.

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

Sources

Official sources checked November 2026. Laws and rates change; check the source for the latest version.