Transcription of § 10139. Workers’ Compensation Claim Form (DWC 1) and ...
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§ 10139. Workers’ Compensation Claim Form (DWC 1) and ...
10139. Workers Compensation Claim Form (DWC 1) and Notice of PotentialEligibility. Note: Authority cited: Sections 133 and 5401, Labor Code. Reference: Sections 132(a), , , 4600, , 4601, , 4616, 4650, 4656, , , 4700, 4701, 4702, 4703, 5400, 5401, and 5402, Labor Code. Rev. 1/1/2016 Page 1 of 3 Workers Compensation Claim Form (DWC 1) & Notice of Potential Eligibility Formulario de Reclamo de Compensaci n de Trabajadores (DWC 1) y Notificaci n de Posible Elegibilidad If you are injured or become ill, either physically or mentally, because of your job, including injuries resulting from a workplace crime, you may be entitled to workers Compensation benefits. Use the attached form to file a workers Compensation Claim with your employer. You should read all of the information below. Keep this sheet and all other papers for your records. You may be eligible for some or all of the benefits listed depending on the nature of your Claim .
Workers’ Compensation Claim Form (DWC 1) & Notice of Potential Eligibility Formulario de Reclamo de Compensación de Trabajadores (DWC 1) y Notificación de Posible Elegibilidad If you are injured or become ill, either physically or mentally, because of your job, including injuries resulting from a workplace crime, you may be entitled to
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