Workers' Compensation Claim Form (DWC-1)Download Form
This form is required to initiate a claim for workers' compensation benefits. Per current law, a verbal report of an injury is not sufficient to initiate a claim for benefits.
This form can be obtained directly from your employer, who is supposed to provide it within 24 hours of a reported injury claim. Or, you can obtain a copy here.
It is important to list any and all parts of body or medical conditions that you relate to your injury when you first fill out this form. Failure to do so could result in delays in your case. After you have filled out the top portion of the form, you are to submit to your employer and they should give you and/or you should request a copy after they fill out the bottom portion.