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What Information Should I Include on my Workers’ Comp Claim Form?

By Kenton Koszdin Law Office on January 15, 2013 | In Workers Compensation Claims

What Information Should I Include on my Workers’ Comp Claim Form?

If you’re injured on the job, you’ll need to fill out a workers’ compensation claim form as soon as you can after the accident. Your employer should provide you a copy of this form, or you can download it from the California Division of Workers’ Compensation website here: http://www.dir.ca.gov/dwc/FileAClaim.htm.

When you give the completed form to your employer, it opens your workers’ compensation claim and protects certain rights you have under California workers’ compensation law. You are responsible for completing the top half of the form, which asks for information like:

  • Contact information. Your name, address, and the date you filled out the form should appear on your completed form.
  • The date and time you were injured, if your injury was the result of an accident or other event.
  • The address and description of the place the injury occurred. This may be at your workplace, at a worksite away from your usual workplace, on the road while you were driving for a work-related task, or at another location. You do not have to be injured at your employer’s specific workplace, as long as you were injured while doing your job.
  • description of your injury, including what happened and which body part or parts were injured.
  • Your Social Security number and your signature.

Your employer is responsible for filling out the bottom half of the form.

The experienced southern California workers’ compensation attorneys at the Kenton Koszdin Law Office can help you with every step of your workers’ compensation claim. To learn more, call us today at (888) 438-3797 for a free, confidential consultation.

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