The State of California Department of Industrial Relations Division of Workers' Compensation (DWC) provides a structured procedure for individuals and companies to request access to a WCAB (Workers' Compensation Appeals Board) case file through the DWC Form AD-1. Filling out this form is the first step in obtaining crucial information related to a specific workers' compensation case, be it for legal, personal, or business reasons. The form requires detailed information about the requester, including name, contact details, and the nature of the requester's business, along with specifics regarding the person or entity they represent, if applicable. Additionally, the exact WCAB case number and the injured worker's name are mandatory fields, ensuring that access is granted for specific, legitimate purposes. The form also includes a section where the requester must explain the reason for wanting access to the case file, emphasizing the importance of transparency and legal compliance. Signing the form requires an acknowledgment that the information obtained will not be used for illegal or unlawful purposes, with serious legal implications highlighted for non-compliance, such as penalties for tampering with or mishandling official documents. This introductory segment highlights the DWC AD-1 form's role in maintaining the integrity and accessibility of workers' compensation case files, while also safeguarding the information from misuse.
| Question | Answer |
|---|---|
| Form Name | Dwc Form Ad 1 |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names |
STATE OF CALIFORNIA
DEPARTMENT OF INDUSTRIAL RELATIONS
DIVISION OF WORKERS' COMPENSATION
REQUEST TO VIEW A WCAB CASE FILE
Instructions: In order to view a WCAB case file, please complete and submit this form to the clerk at the front counter. Your request will be reviewed by a supervisor and you will be informed of the decision as soon as possible.
1. PLEASE COMPLETE THE FOLLOWING (Please Print):
Requester Name:
DWC Authorization # (if any):
Company Name:
Address:
City/State/Zip:
Telephone:
Nature of requester's business:
2.IF YOU ARE MAKING THIS REQUEST ON BEHALF OF ANOTHER, PLEASE PROVIDE THE FOLLOWING DATA ABOUT THE PERSON OR ENTITY YOU REPRESENT:
Name:
Company Name:
Address:
City/State/Zip:
Telephone:
Nature of business:
3.PLEASE PROVIDE THE FOLLOWING: WCAB Case Number:
Injured Workers Name:
(Please complete reverse side of form) |
DWC Form |
4.PLEASE EXPLAIN WHY YOU WANT THIS INFORMATION AND THE REASON WHY YOUR CLIENT WANTS THIS INFORMATION:
5. PLEASE READ THE FOLLOWING AND SIGN AS INDICATED BELOW.
NOTE: This Request is a Public Record. A copy of this record will be retained by the DWC District Office. By making this request you are declaring that you will not use the information you receive for illegal or unlawful purposes.
I, the undersigned, declare under penalty of perjury under the laws of the State of California, that I shall not use the information received pursuant to this request for illegal or unlawful purposes and that the foregoing is true and correct.
I agree to replace all the papers in the file in the same order and position as received. I am aware that it is a crime punishable by imprisonment to steal, secrete, remove, destroy, mutilate, deface or alter any paper in the file. (Government Code Section
Signature |
Date |
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( To be complete by the Division of Workers' Compensation Only)
Your request to view the WCAB case file has been granted.
Your request to view the WCAB case file has been denied because