DWC Form AD 1 is a critical form that must be filed in order to establish a workers' compensation claims procedure. This article will provide an overview of the information that must be included on this form. If you are injured while working, it is important to file a workers' compensation claim as soon as possible. The DWC Form AD 1 is the first step in the process of filing a workers' comp claim. This form must be completed and filed with the Texas Department of Workers' Compensation within 30 days of the accident or injury. The information required on DWC Form AD 1 includes your name, Social Security number, date of birth, address, employer's name and address, and nature of injury. You must also indicate whether you have hired an attorney to represent you in your workers' comp case. To file a workers' compensation claim in Texas, download and complete DWC Form AD 1 from the TDWC website: https://www1.tdwc.state.tx.us/pubforms/formad1.pdf
| 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