Application For Adjudication Of Claim {WCAB 1}

DWC/WCAB Form 1A, APPLICATION FOR ADJUDICATION OF CLAIM. This form is used in the state of California in workers' compensation cases. This form is used by an employee to initiate a claim for workers' compensation benefits. The purpose of the Application for Adjudication of Claim is to formally request that a workers' compensation judge review and decide on the validity of the employee's claim. The form requires the employee to provide information about their name, contact information, and the date and circumstances of their injury or illness. The employee must also provide information about their employer and their employer's workers' compensation insurance carrier. Once the employee files the Application for Adjudication of Claim, a case number will be assigned and the case will be processed in the workers' compensation system. (Rev. 5/2020). www.FormsWorkflow.com