3 Things You Must Include On Your Worker’s Comp Application

shutterstock_153986042To receive benefits under workers’ compensation, the correct forms must be submitted to the California State Division that determines eligibility for claims.  All statements have to be true and verifiable, and the penalty for false statements is charged as a felony.  A successful application will have three essential components in order to qualify for eligibility.


1.     The application requires that you state your name, address and social security number for identification purposes.  It is important that your name be listed the same way as in your employee and tax records to make sure that benefits reach you.  Signing and dating the application affirms that the contents are correct and accurate to the best of your knowledge.


2.     You must state the date and time the injury occurred at the workplace.  Be specific on whether it was morning or afternoon.  Also list the address and description of location where the injury occurred.  For example, at “XYZ Plant, at ABC Street, (City, State,) in the electrical room located in the basement of Building A.”  Be as specific as possible in describing the location within the room as well, to give a clear picture of where you were when you were injured.


3.     It is necessary to give a detailed description of the injury itself and the part of the body that was injured.  If there were multiple injuries describe each one separately.  You are not making a medical assessment, but just giving a factual account of what happened.  “After coming into contact with an exposed electrical plate, the skin on my left hand was burned on the back, creating painful blisters and redness.  I also hit my head on an overhanging pipe as I jumped back, causing a head injury with swelling and bruising.”  With these details the Division can assess the extent of injury and qualification for necessary medical treatment.


Because workers’ compensation benefits are extended without a showing of fault, it is not necessary to elaborate on the cause of the injury.  Even if you think it resulted from an unsafe condition that does not need to be in the application.


The Division of Workers’ Compensation is an administrative body that handles benefits and qualification, so all that you are showing is that you are an employee and the injury occurred on the job.  After the application is approved you will be eligible for medical care and if necessary lost wage benefits for time needed for recovery.

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