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Form Dwc041 Rev 03 07 Demand Assistance

hi there I'm Michael Rob with height and.rotten ortley.here in San Diego California and today.we're going to talk about employee claim.forms in the workers compensation area.the form you have in front of you is the.workers compensation claim form also.known as the DWC one.most of it is self-explanatory and.within one working day of your injury.provided that your employer has notice.of your injury they're required by law.to provide you with a form like you see.in front of you here now it's your.obligation to fill out items one through.eight most of these are self-explanatory.but we're going to walk through them.anyway the first one is the name and.then the today is date that you filled.out the form your address your city and.state and zip code and the date of.injury.now as for the date of injury if you.were hurt today August 1st then that's.the date that she would put along with.the approximate time now if you're.unclear on whether or not you were.injured today or you've been injured.within the last few days and based upon.the repetitive nature of your job it.could even be a few weeks ago could have.been within the past year you'll put the.letters C as in Charlie T isn't Tom in.front of today's date and today's date.being the last date that you worked.before giving notice of your injury to.your employer I do want to point out at.this at this juncture that this form is.also in Spanish so you're not required.to fill it out in English you can fill.it out in Spanish and the directions are.in Spanish as well now moving on to item.5.the address and description of where the.injury occurred you can put just job.site you can put the address or if.you're say in a car running an errand.for your employer you can put the.approximate location and then also how.the injury happened now.item six you will describe the injury.and the body parts affected if it was.your your neck your hands your eye and.any body part that was affected and.typically you'll also include pain.because as everyone knows if you've.injured yourself.typically pain follows the injury also.something to keep in mind you may or may.not have problems sleeping because of.the pain or discomfort so you'll want to.include sleeping disorder just so your.claim includes that if in fact that's.something that you are experiencing the.next item is item 7 your social security.number and finally item 8 your signature.you'll need to sign that now before you.turn this over to your employer or their.Human Resources agent you'll want to.make sure that you keep a copy of this.for your records within one day of.providing this form to your employer.they were then required to provide.they're filled out section to you and.also required to turn this over their.insurance company so if you have any.further information or any further.questions please contact us at height.and rotten ortley w whro.LLP comm I hope this is helpful and look.forward to talking to you again thank.you.

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