New Workers Compensation Claim Form (DWC1) effective 1/1/16

The Department of Industrial Relations has updated the DWC1 claim form as of 1/1/16 and this form should be utilized and provided to employees for any work related injury, regardless of injury date. The prior DWC1 is obsolete and should no longer be used. There is no change to the CharterSAFE Call-In Report procedure.
The new form (download below) now provides the option to receive all notices and letters via email and includes a space for an email address (#8).
The biggest change to the form is found within the information for injured workers section, which has gone from 2 to 3 pages and is much more thorough and detailed.  The form is in English and Spanish.  New additions include:
  • Treatment: Advises that there are limits to certain types of treatment, including chiropractic and therapy and also how to resolve issues with authorization and/or denials of treatment.
  • Treating physicians: How and when to change  primary treating physicians
  • Returning to work: Encourages return to work as soon as possible and briefly goes over "modified duty"
  • Problems/disputes: References for resolving issues, including where to turn if the employee is not receiving benefits
  • Websites and toll free numbers for questions.
Please be sure that injured employees are provided all 4 pages when they report a work related injury/illness. They should also retain the information portion of the form for their future reference.  Any questions or concerns? Please contact Susan Diamanti at 818-239-9552 or via email at

Susan Diamanti, WCCP
Workers Compensation Director
Mailing address: 6520 Platt Avenue, #250
West Hills, CA 91307
Phone: (818) 239-9552
Claim call in #: 877-263-9904
Fax: (916) 720-0324

Click the link below to download the new form.
DWC1 Effective 1-1-16
(Adobe PDF File)
Your Primary Workers'
Compensation Contact is

Susan Diamanti

Workers' Compensation Director

Phone: 818.239.9552
Fax: 530.637.5701