Bulletin No. 36-04
July 28, 2004


Final claim form, poster, and employee notice regulations go into effect Aug. 1

Final regulations that revise the DWC Form 1 (claim form), the workplace poster, and information employers are required to provide employees at time of hire have been approved by the state Office of Administrative Law and are effective Aug. 1, 2004. The revised regulations and forms can be found on the DWC web site at: http://www.dir.ca.gov/dwc/DWCPropRegs/DWCClaimFormReg.htm.

The revisions reflect changes in the law contained in the following reform bills: Assembly Bill 749, Assembly Bill 277, Assembly Bill 228, and Senate Bill 899. The revised materials include:

  • A newly designed claim form, which includes the Notice of Potential Eligibility as required by Assembly Bill 749. Employers should begin using this form on Aug. 1, 2004 regardless of the date of injury. Employers may download and use the claim form posted on the DWC web site at: http://www.dir.ca.gov/dwc/forms.html.

  • Revised language for the Notice to New Employees. Employers and carriers need to update the notice they are using to reflect the new regulations and submit the revised version to the DWC administrative director for review and approval. The separate notice to employees at time of injury is no longer required.

  • Revised language for the Notice to Employees Poster. Claims administrators and employers need to revise the notice they are using and submit the revised notice to the DWC administrative director for review and approval. Alternatively, they may download and use the version posted on the DWC web site.

    Please note that employers may obtain professionally printed copies of the claim form and poster from their claims administrator.

    Because of the short time frame before the effective date of these regulations, DWC will expedite, to the maximum extent possible, the review and approval process for the Notice to New Employees and Notice to Employees Posters. Also, in order to allow for a reasonable period of time for claims administrators to print an adequate supply of the revised claim forms and distribute them to their clients, the DWC Audit Unit will not start assessing penalties for failure to provide injured workers the new claim form until Oct.1, 2004.

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