This information is provided free of charge by the Department of Industrial Relations from its web site at These regulations are for the convenience of the user and no representation or warranty is made that the information is current or accurate. See full disclaimer at

Chapter 4.5. Division of Workers' Compensation
Subchapter 1.5. Injuries on or After January 1, 1990

New query

§ 10138. Claim Form and Notice of Potential Eligibility for Benefits.

The employee's form for filing a workers' compensation claim (DWC 1) and the Notice of Potential Eligibility for Benefits is a mandatory form set forth in Section 10139 of this Article. The employer portion of the form may also include other information pertinent to the claim, including a logo or other employer-identifying information, but such information shall in no way impose additional duties or prohibitions on the employee or delay the processing of the claim. The claim form consists of an original and three (3) copies.

     Note: Authority cited: Sections 133 and 5307.3, Labor Code. Reference: Sections 5401, 5401.7 and 5402, Labor Code.  

1. Change without regulatory effect renumbering former section 10117.1 to section 10138, including amendment of section, filed 4-7-2008 pursuant to section 100, title 1, California Code of Regulations (Register 2008, No.15).

Go BackGo Back to Article 9 Table of Contents