Workers' Compensation Claim Form (DWC-1) & Notice of Potential Eligibility, Rev. 1/16

New 6-part claim form/NOPE, effective 1/1/16 --- Note: MUST be used beginning 1/1/16

The form that injured workers, their dependents or agents use to file a claim for workers' compensation benefits in California (LC 5401, CCR 10139.) This form was revised by the state in September 2015 and took effect 1/1/16. Changes include a new 3-page Notice of Potential Eligibility as well as revisions to the DWC-1 claim form. California law requires employers to provide employees with the DWC-1 form and Notice of Potential Eligibility within one working day of receiving notice or knowledge of a work injury or illness (beyond first-aid.) The 6-part form is printed in English and Spanish, with the state-mandated Notice of Potential Eligibility printed as a cover sheet attached to four copies of the claim form printed on NCR paper: one as the employee's temporary receipt when they first file the claim; and one each for the employer and the claims administrator, and one as the employee's final copy that should be signed and dated by the employer after completing their portion of the form (new 6-part claim form/NOPE, effective 1/1/16.)

sets of 100 for $51.00 (bulk discount available)