Workers Compensation Forms

Administration Building, Room 601

Hours: Monday - Friday from 8 a.m. to 5 p.m.

Phone (323) 343-3657 | Fax (323) 343-3662

Workers' Compensation Forms

Titles and Descriptions

PDF

Word

Employee's Report of Occupational Injury or Illnessused by employees to report an occupational injury or illness

Employee's Report of Occupational Injury or Illness-PDF  

Supervisor's Report of Occupational Injury or Illnessused by supervisors to report an occupational injury or illness

Supervisor's Report of Occupational Injury or Illness-PDF  

Workers' Compensation Personal Physician Designationused by employee to designate a personal physician for occupational injury or illness; must be completed before occupational injury or illness

Workers' Compensation Personal Physician Designation-PDF Workers' Compensation Personal Physician Designation-DOC

Workers' Compensation Claim Form (DWC 1)used by employee

Workers' Compensation Claim Form (DWC 1)-PDF