Workers' Compensation Claim Kit - California

18. Date employee was provided Workers’ Compensation Claim Form (DWC 1) - Enter the date the form was given or mailed to the employee. 19. Specific injury or illness and medical diagnosis - Indicate the nature of the injury/ illness. 19a. Body Part Affected - Use the exact part(s) of body injured. Include left or right, upper or lower, etc. 20. ................
................