STATE OF CALIFORNIA
DIVISION OF WORKERS' COMPENSATION
WORKERS' COMPENSATION APPEALS BOARD
APPLICATION FOR ADJUDICATION OF CLAIM
Applicant (If other than Injured Worker)
Injured Worker (Completion of this section is required)
DWC/WCAB Form 1A (11/2008) - (Page 1)
Venue choice is based upon (Completion of this section is required)
Select 3 - Letter Office Code For Place/Venue of Hearing (From the Document Cover Sheet)
WCAB1
Zip Code
City
Street Address2/PO Box (Please leave blank spaces between numbers, names or words)
Street Address/PO Box (Please leave blank spaces between numbers, names or words)
Name (Please leave blank spaces between numbers, names or words)
SSN (Numbers Only)
Case No.
Amended Application
County of residence of employee (Labor Code section 5501.5(a)(1) or (d).)
County where injury occurred (Labor Code section 5501.5(a)(2) or (d).)
County of principal place of business of employee’s attorney (Labor Code section 5501.5(a)(3) or (d).)
Zip Code
MI
First Name
Last Name
Street Address/PO Box (Please leave blank spaces between numbers, names or words)
Street Address2/PO Box (Please leave blank spaces between numbers, names or words)
International Address (Please leave blank spaces between numbers, names or words)
City
State
State
Insurance Carrier Employer Lien Claimant
Print Form
Reset Form
IT IS CLAIMED THAT (Complete all relevant information):
, while employed as a(n)
1. The injured worker, born
suffered a :
Street Address/PO Box - Please leave blank spaces between numbers, names or words
.
Employer Information (Completion of this section is required)
Insurance Carrier Information (If known and if applicable - include even if carrier is adjusted by claims administrator)
Claims Administrator Information (If known and if applicable)
(Choose only one)
and ended on
which began on
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DWC/WCAB Form 1A
(11/2008) - (Page 2)
(DATE OF BIRTH: MM/DD/YYYY)
(Date of injury: MM/DD/YYYY)
Zip Code
City
Employer Street Address/PO Box (Please leave blank spaces between numbers, names or words)
Employer Name (Please leave blank spaces between numbers, names or words)
Insured
Self-Insured Legally Uninsured Uninsured
Zip Code
State
City
Street Address/PO Box (Please leave blank spaces between numbers, names or words)
Name (Please leave blank spaces between numbers, names or words)
Zip Code
City
Insurance Carrier Street Address/PO Box (Please leave blank spaces between numbers, names or words)
Insurance Carrier Name (Please leave blank spaces between numbers, names or words)
City
The injury occurred at
(End Date: MM/DD/YYYY)
(Start Date: MM/DD/YYYY)
(OCCUPATION AT THE TIME OF INJURY)
specific injury
cumulative injury
State
State
,
State
Zip Code
4. The injury caused disability as follows:
5. Compensation:
Compensation was paid:
6. Has the worker received any unemployment insurance benefits and/or any unemployment compensation
disability benefits (state disability) since the date of injury?
2. The injury occurred as follows:
3. Actual earnings at the time of injury:
MM/DD/YYYY
MM/DD/YYYY MM/DD/YYYY
MM/DD/YYYY
MM/DD/YYYY
(State which parts of the body were injured)
MM/DD/YYYY
First Period of Disability:
Second Period of Disability:
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DWC/WCAB Form 1A
(11/2008) - (Page 3)
(EXPLAIN WHAT THE WORKER WAS DOING AT THE TIME OF INJURY AND HOW THE INJURY OCCURED)
Rate of Pay $
Monthly
Weekly
Hourly
State value of tips, meals, lodging, or other
advantages, regularly received $
Number of hours worked per week
Last day off work due to injury:
Start Date
End Date
End Date
Start Date
Yes No
Date of last payment:
Yes No
Total paid:
Weekly rate(s):
Monthly
Weekly
Hourly
Body Part 1:
Body Part 2:
Body Part 3:
Body Part 4:
Other Body
Parts:
8. Other cases have been filed for industrial injuries by this worker as follows:
9. This application is filed because of a disagreement regarding liability for:
Names and addresses of doctor(s)/hospital(s)/clinic(s) that treated or examined for this injury, but that were not
provided or paid for by the employer or insurance carrier:
Did Medi-Cal pay for any health care related to this claim?
(NAME OF PERSON OR AGENCY PROVIDING OR PAYING FOR MEDICAL CARE)
7. Medical treatment:
Medical treatment was received:
All treatment was furnished by the Employer or Insurance Carrier:
Date of last treatment:
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DWC/WCAB Form 1A
(11/2008) - (Page 4)
Yes No
MM/DD/YYYY
Yes No
Other treatment was provided/paid by:
Yes No
Name of Doctor/Hospital/Clinic 1 (Please leave blank spaces between numbers, names or words)
Name of Doctor/Hospital/Clinic 2 (Please leave blank spaces between numbers, names or words)
Temporary disability indemnity
Reimbursement for medical expense
Medical treatment
Compensation at proper rate
Permanent disability indemnity
Rehabilitation
Supplemental Job Displacement/Return to Work
Other (Specify)
Case Number 2
Case Number 1
Case Number 4
Case Number 3
City
, California
MM/DD/YYYY
Is the Applicant Represented?
Applicant Attorney/Representative Signature
Applicant Signature
If "No", applicant is to sign and date below.
If "Yes", applicant’s representative is to complete the following and is to sign and date below.
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DWC/WCAB Form 1A
(11/2008) - (Page 5)
Yes No
MI
Dated at
Date
Zip Code
City
Law Firm or Company Name (If Applicable)
Law Firm Number (If Applicable)
Attorney/Representative Last Name
Attorney/Representative First Name
Law Firm/Attorney Non-Attorney Representative
State
Street Address/PO Box (Please leave blank spaces between numbers, names or words)
INSTRUCTIONS
FILING AND SERVICE OF A DECLARATION OF READINESS IS A PREREQUISITE TO THE SETTING OF A
CASE FOR HEARING.
Effect of Filing Application
Filing of this application begins formal proceedings against the defendant(s) named in your application.
Assistance in Filling Out Application
You may request the assistance of an information and assistance officer of the Division of Workers' Compensation.
Right to Attorney
You may be represented by an attorney or agent, or you may represent yourself. The attorney's fee will be set by the
Workers' Compensation Appeals Board at the time the case is decided and is ordinarily payable out of your
award.
Filling Out Application
For "amended" applications, the venue choice must be the same as that specified on the original application, unless an
order changing venue has issued. A street or P.O. Box address within the United States must be entered for the place
where the injury occurred. Therefore, if the injury did not occur at a fixed or identifiable location (such as a field, a
highway,or on water), or if the injury occurred outside of the United States, the employer's business address or another
appropriate address must be specified; however, a short explanation regarding the place of injury may be appended to
the application. If medical treatment has been paid for by Medi-Cal, Medicare, group health insurance, or a private carrier,
please specify.
Service of Documents
Your attorney or agent will serve all documents in accordance with Labor Code section 5501 and the Workers'
Compensation Appeals Board's Rules of Practice and Procedure.
If you have no attorney or agent, copies of this application will be served by the Workers' Compensation Appeals
Board on all parties. If you file any other document, you must mail or deliver a copy of the document to all parties in the
case.
IMPORTANT!
If any applicant is under 18 years of age, it will be necessary to file a Petition for Appointment of Guardian ad Litem.
Forms for this purpose may be obtained at the district office of the Workers' Compensation Appeals Board, or by
calling the district office and requesting this form.
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DWC/WCAB Form 1A
(11/2008) - (Page 6)
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