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Forms

Employee/Volunteer Injury/Illness Report [PDF]
Supervisor Injury/Illness Report [PDF]
Witness Report of Injury/Illness [PDF]
Notice of Personal Chiropractor or Personal Acupuncturist [PDF]
Physician Pre-Designation
Workers' Compensation Claim Form (DWC1) & Notice of Potential Eligibility [PDF]

Submitting Forms & Documents

Please submit Workers' Compensation form(s) and supporting documents to our Workers' Compensation Secure Dropbox or deliver to WH 340.

荔枝视频, Dominguez Hills

1000 E. Victoria Street
Carson, CA 90747
310-243-3696

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