How to Fill Out and Submit the California DWC-1 Form

The California DWC-1 form is the state’s official workers’ compensation claim form, and filing it with your employer is what formally starts your claim for medical treatment and wage-replacement benefits. Your employer must give you the form within one working day of learning about your injury, and you can also download it directly from the Department of Industrial Relations.¹ Once you return the completed form, your employer must authorize up to $10,000 in medical care while the insurance company investigates, and if the insurer doesn’t deny the claim within 90 days, the injury is legally presumed to be work-related.²

Filling Out the Employee Section

The DWC-1 is a two-part document: a claim form you fill out and a Notice of Potential Eligibility that explains the benefits you could receive. The form itself is bilingual in English and Spanish and available in Chinese, Korean, Tagalog, and Vietnamese from the DIR website.¹ Under Labor Code 5401, the form is also available at district offices of the Employment Development Department and the Division of Workers’ Compensation.³

The employee section has nine numbered fields:⁴

Field 1 asks for your full legal name and the date you are filling out the form, not the date of the injury.
Field 2 is your current residential street address.
Field 3 is your city, state, and zip code.
Field 4 is the exact date and time of the injury, including whether it happened in the a.m. or p.m. For cumulative injuries such as repetitive stress, use the date you first noticed the condition or the date a doctor told you it was work-related.
Field 5 asks where the injury happened — the street address and the specific area within the workplace, such as “loading dock,” “second-floor break room,” or “parking lot behind building B.”
Field 6 asks for a description of the injury and every body part affected. Thoroughness here matters; if your back, neck, and left shoulder were all hurt, name all three.
Field 7 is your Social Security number.
Field 8 is an opt-in box for receiving claim notices by email only, with space for your email address.
Field 9 is your signature.

Writing the Injury Description

Field 6 is where most mistakes happen. Write in plain, specific language. “I slipped on a wet floor in the warehouse and landed on my right hip, and I also hit my head on the concrete” is far more useful than “I fell and got hurt.” If you developed a condition gradually, such as carpal tunnel from typing or hearing loss from machinery noise, describe the activity, how long you’ve been doing it, and when symptoms started. What you write here should line up with what you tell the doctor, because the claims administrator will compare the two.

List every affected body part, even ones that seem minor at the time. Secondary symptoms often appear days or weeks after the injury, and if your original form mentions only your back but you later need shoulder surgery, the insurer has grounds to argue the shoulder isn’t covered. Erring on the side of being too thorough costs you nothing.

Submitting the Form to Your Employer

After you complete the employee section, deliver the form to your employer. Hand-delivery works, but certified mail with a return receipt gives you a dated record proving when your employer received it. That timestamp matters because it starts several legal clocks: the employer’s duty to authorize medical care, the 14-day window for the initial claim response, and the 90-day investigation period.

Keep copies of everything, including the completed form, any mailing receipts, and the dated copy your employer is required to hand back to you. Within one working day of receiving the completed DWC-1, your employer must fill out the employer section, give you a dated copy, keep one copy, and forward one to the claims administrator.⁴

Verbal reports of an injury do not substitute for the written claim form. Until the DWC-1 is in your employer’s hands, none of the statutory deadlines or medical-treatment obligations kick in.

What Filing Triggers

Filing the DWC-1 shifts most of the responsibility onto the employer and the insurance carrier.

Within one working day after you file the form, your employer must authorize medical treatment. While the claim is being investigated, the insurer’s liability for that treatment is capped at $10,000.² You should be able to see a doctor right away, without waiting for formal acceptance. The treatment must be consistent with California’s medical treatment utilization schedule, but you should not be denied care during this window simply because the investigation is still open.

The claims administrator then has 14 days from receiving notice of your claim to send you a letter stating whether the claim is accepted, delayed for further investigation, or denied.⁴ If the insurer needs more time, the claim enters a delayed status, but the $10,000 in authorized medical care continues.

The outer deadline is 90 days from the date you filed the claim form. If the insurer fails to deny the claim within those 90 days, the injury is legally presumed compensable, and the insurer can only rebut that presumption with evidence discovered after the 90-day period expired.²

Deadlines You Need to Watch

California workers’ compensation runs on tight timelines. The two most important ones fall on you as the worker.

First, you must give your employer written notice of the injury within 30 days of when it occurred. This notice is separate from filing the DWC-1 and is an initial written heads-up. For sudden injuries, the 30 days starts on the date of the accident. For cumulative injuries, it starts when you knew or should have known the condition was work-related.⁵

Second, you generally have one year from the date of injury to begin proceedings to collect benefits.⁶ If your employer never gave you a DWC-1 form, that doesn’t extend your one-year window. Download the form yourself and file it.

The employer-side deadlines also matter because they are things you can enforce. The employer has one working day to provide the form once they learn of an injury that causes missed work time or requires more than first aid, either personally or by first-class mail.³ One working day after you file, they must authorize up to $10,000 in treatment. Fourteen days after the administrator receives the claim, you should have a written response in hand.

Who Can File

Any worker classified as an employee in California can file a DWC-1 for a work-related injury or illness. Independent contractors are generally not covered. Under the state’s ABC test, a worker is presumed to be an employee unless the hiring company proves the worker is free from the company’s control over how the work is done, performs work outside the company’s usual business, and has an independently established business doing the same type of work.⁷ A contract label alone doesn’t settle the question. The actual working relationship does.

The form covers injuries from a single event, such as a fall, a burn, or a car accident on a work errand, and cumulative conditions that develop over time, such as repetitive strain, hearing loss, or occupational lung disease. It also covers mental health conditions caused by the job, though those claims face additional scrutiny.

If You’re Worried About Retaliation

California law makes it a misdemeanor for an employer to fire, threaten to fire, or discriminate against you for filing a workers’ compensation claim. If your employer retaliates, you are entitled to reinstatement, reimbursement for lost wages and benefits, and a 50 percent increase in your workers’ compensation benefits, capped at $10,000. You have one year from the retaliatory act to file a petition with the Workers’ Compensation Appeals Board.⁸

The same rule applies to insurers. If an insurance company pressures your employer to fire you because you filed a claim, the insurer is also guilty of a misdemeanor and subject to the same penalty increases. Proving retaliation requires showing you were singled out specifically because of the claim, which can be hard without documentation. Save copies of any unusual write-ups, schedule changes, or communications that followed your filing.

1
California Department of Industrial Relations. DWC Forms
2
California Legislative Information. California Code Labor Code 5402
3
California Legislative Information. California Code LAB 5401
4
Department of Industrial Relations. Workers’ Compensation Claim Form (DWC 1) and Notice of Potential Eligibility
5
California Legislative Information. California Code LAB 5400
6
Justia. California Code Labor Code 5405
7
Labor and Workforce Development Agency. ABC Test
8
California Legislative Information. California Code LAB 132a