Report your injury to your employer IMMEDIATELY — delays can weaken your claim

California law presumes your claim is accepted if the insurer does not deny within 90 days

You have the right to change treating physicians after 30 days if your employer uses a Medical Provider Network (MPN)

Workers' Compensationmoderate

California Workers' Comp Claim Form

DWC-1 · California Division of Workers' Compensation

Employee claim form for workers' compensation benefits in California. Employer must provide within one working day of learning of a workplace injury or illness.

Form Details

Total fields: 38
Auto-fillable: 24 (63%)
Time without BeneFill: 25 minutes
Time with BeneFill: 7 minutes
Time saved: 18 minutes
Filled by: patient
Frequency: per incident
State-specific: Yes — form may vary by state

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Where to Submit This Form

📬

Employer provides this to the employee

Your employer is required to provide you with a DWC-1 claim form within 1 business day of learning of your injury.

Filing Deadline

Employee should return the completed form to the employer within 1 year of the injury or knowledge of the injury. Return it as soon as possible.

Required Attachments

📎 Employee completes the Employee section
📎 Employer completes the Employer section and forwards to their workers' comp insurer

Processing Time

The insurer must authorize up to $10,000 in treatment within 1 day of receiving the claim. They have 90 days to accept or deny the claim.

What Happens Next

Your employer's insurer must authorize treatment immediately (up to $10,000 presumptive). You will be assigned a claims adjuster. The insurer has 90 days to accept or deny.

Tips for This Form

✓ Report your injury to your employer IMMEDIATELY — delays can weaken your claim
✓ California law presumes your claim is accepted if the insurer does not deny within 90 days
✓ You have the right to change treating physicians after 30 days if your employer uses a Medical Provider Network (MPN)
✓ For more info: https://www.dir.ca.gov/dwc/

You Might Also Need

Workers' Comp Treatment Authorization Request

UR/PA (state/insurer specific) · Workers' Comp Insurers / UR Organizations

Request for approval of specific medical treatment, surgery, or diagnostic test related to a workplace injury. Insurer must respond within state-mandated timeframes.

First Report of Injury (Generic FROI)

FROI · State Workers' Compensation Agencies

Report of workplace injury or occupational disease filed with the state agency and insurer. Required within 3-10 days of injury depending on state. Establishes the claim in the system.

New York Employee Claim

C-3 · New York Workers' Compensation Board

Employee's claim for compensation filed with the NY Workers' Compensation Board. Must be filed within 2 years of the accident or within 2 years of when the claimant knew or should have known the condition was work-related.

Texas Employee's Claim for Compensation

DWC-041 · Texas Department of Insurance, Division of Workers' Compensation

Employee's claim for compensation for a work-related injury or illness in Texas. Must be filed within one year of injury or within one year of when the employee knew or should have known the condition was work-related.

Florida First Report of Injury or Illness

DFS-F2 · Florida Division of Workers' Compensation

Florida's first report of injury or illness form. Employer must file within 7 days of knowledge of an injury or within 24 hours if the injury results in death.

North Carolina Notice of Accident to Employer

Form 18 · North Carolina Industrial Commission

Notice of Accident to Employer and Claim of Employee. Must be filed when injured on the job in North Carolina. Written notice to employer required within 30 days; claim filed within 2 years.

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Disclaimer: BeneFill™ provides form-filling assistance and informational guidance only. It is not affiliated with, endorsed by, or sponsored by the California Division of Workers' Compensation or any government agency. The information provided is for general informational purposes and does not constitute legal, medical, financial, or tax advice. Always verify form requirements and submission details directly with the issuing agency.