Workers' Compensation Claim Form - DWC 1 - Spanish

If an employee suffers a work-related injury or illness, he or she may be entitled to workers' compensation benefits. Give this form to the employee and have him /her complete the "Employee" section and then return the form to you. Give the employee the copy marked "Employee's Temporary Receipt," providing the employee with a dated copy when you have completed the form. All employees should also have received a pamphlet describing workers' compensation benefits and procedures to obtain them.​​ This form has been made available by the Department of Industrial Relations for use with non-English speaking employees.