How to Fill Out California WCAB DWC-AD 1 (w/Examples) + FAQs

The California WCAB DWC-AD Form 1 is the Application for Adjudication of Claim that an injured worker, dependent, lien claimant, or attorney files with the Workers’ Compensation Appeals Board to formally open a case and let a judge decide disputed workers’ compensation issues. Filing this single page begins your right to a hearing, secures jurisdiction over your employer and its insurance carrier, and stops the one-year statute of limitations under Labor Code §5405 from killing your claim.

The current revision is the DWC-AD 1 (Rev. 1/2017), and the Division of Workers’ Compensation hosts the official PDF you must use. Last fiscal year, more than 138,000 Applications for Adjudication were filed across California’s 24 WCAB district offices, and roughly 1 in 7 are rejected at intake for missing fields, wrong venue, or bad proof of service, according to DIR annual reporting.

Here is what you will learn:

• 📝 How to fill out every box on the DWC-AD 1 line by line
• ⏰ The deadlines that control your case under Labor Code §§5405, 5406, and 5412
• 🏛️ How to pick the correct WCAB district office venue under §5501.5
• 📂 Which attachments, cover sheets, and proofs of service the EAMS portal requires
• ❌ The mistakes that get applications rejected and how to avoid them

What the DWC-AD 1 Is and Who Must File It

The DWC-AD 1 is the official Application for Adjudication of Claim under California Code of Regulations, Title 8, §10450. Filing it asks the WCAB to take jurisdiction over a workers’ compensation dispute. Without an Application on file, no judge can issue an award, approve a Compromise & Release, or rule on a lien.

The form is not the same as the DWC-1 Claim Form you give your employer to start a claim. The DWC-1 notifies the employer; the DWC-AD 1 opens a case file at the appeals board. Many injured workers confuse the two and lose months of benefits.

You must file the DWC-AD 1 if you are an injured worker whose claim is denied, delayed, or undervalued, a surviving dependent under Labor Code §5406, a lien claimant seeking payment, or an attorney representing any of the above. Employers and carriers can also file a Defendant’s Application if they want a judge to decide an issue first.

The form is governed by Labor Code §5500 and the WCAB Rules of Practice and Procedure. The agency that receives it is the WCAB district office with proper venue, and the penalty for filing late is dismissal under §5405, which permanently bars your claim.

Before You Start: Documents and Information You Need

Gather everything below before you open the form. Missing one item is the most common reason an Application gets bounced at the EAMS intake desk.

• Your full legal name, address, and phone number. The WCAB mails every notice here, and a wrong address means missed hearings and dismissal.
• Your Social Security Number. Required by 8 CCR §10402 for case indexing; missing SSN delays case opening.
• Date of injury. For specific injuries, the actual date; for cumulative trauma, the date under Labor Code §5412.
• Employer’s exact legal name and address. A DBA instead of the legal entity can void service.
• Insurance carrier and claims administrator. Two different entities; both must be named.
• Body parts injured. Use the DWC body part codes so the case routes correctly.
• Average weekly wage. Drives indemnity rates under Labor Code §4453.
• Copy of your filed DWC-1 Claim Form. Proof your employer was notified.
• Any medical reports. PR-2s, QME reports, or treating-doctor notes you plan to attach.
• Proof of service. A completed Proof of Service showing every defendant was served.

Each item maps to a specific box on the form. Skipping a box because you “don’t know yet” is worse than guessing carefully, because EAMS will reject a blank case caption outright.

Where to Get the Form and How to Access It

The official PDF lives on the DWC Forms page under “Application for Adjudication of Claim.” Always download a fresh copy; old PDFs floating on third-party sites often lack current barcodes that EAMS scanners read.

You can also pick up a paper DWC-AD 1 at any of the 24 WCAB district offices. The Information & Assistance Officer at each office hands them out free and will answer basic questions, though they cannot give legal advice.

Attorneys and high-volume filers use JET File through approved vendors that push the form straight into EAMS. Pro se filers usually upload the completed PDF through the district office’s e-filing window or walk it in.

The form’s revision stamp reads DWC-AD 1 (Rev. 1/2017) in the bottom-left corner. If your downloaded PDF shows a different date, replace it before filing. EAMS bounces obsolete revisions during overnight optical character review.

Step-by-Step: How to Fill Out DWC-AD 1 Line by Line

The DWC-AD 1 looks short, but every box has a legal consequence. Follow each H3 below in the order printed on the form.

Case Caption: Applicant Name (Top of Form)

This top line asks for the full legal name of the injured worker (or the deceased worker, if a dependent files). Write it the way it appears on your driver’s license or Social Security card.

Type the name in ALL CAPS, last name first, then a comma, then first and middle: LOPEZ, MARIA ELENA. EAMS indexes by the comma-separated format.

A common nuance is name changes after marriage or divorce. If your DWC-1 was filed under a former name, list both: LOPEZ (FORMERLY GARCIA), MARIA ELENA, so the WCAB can match prior records.

A common mistake is using a nickname like Mary instead of Maria. The case will index under the wrong letter and your file will be impossible to locate at the hearing window.

A common misconception is that the caption can be amended later for free. It can be amended, but only by filing a Petition to Amend, which costs time and may delay your first hearing by 60 days.

Box 1: Applicant’s Address, City, State, ZIP

Box 1 asks where the WCAB should mail every Notice of Hearing, Order, and Award. Use a residential or mailing address you actually check.

Write the street number, street name, apartment, city, two-letter state code, and ZIP+4 if you know it: 4421 Mission St., Apt. 3B, San Francisco, CA 94112-2017.

If you live in a shelter, use a trusted friend’s address or a P.O. Box. The form accepts P.O. Boxes, but you should also list a physical address if you have one, so subpoenas can be served.

A common mistake is listing a job-site address. Once your case starts, you may be off work, and mail will pile up at a place you can no longer enter.

A common misconception is that updating the post office’s change-of-address forwards WCAB mail. It does not; you must file a Notice of Change of Address directly with the district office.

Box 2: Applicant’s Date of Birth and Social Security Number

Box 2 captures date of birth in MM/DD/YYYY format and the full nine-digit SSN. Both fields are mandatory under 8 CCR §10402.

Write the DOB with slashes, no dashes: 03/14/1985. Write the SSN with hyphens: 555-12-3456.

If you are an undocumented worker without a true SSN, write the ITIN in the SSN box and attach a one-line cover note explaining the substitution. California workers’ comp covers undocumented workers under Labor Code §3351.

A common mistake is writing only the last four digits. EAMS rejects partial SSNs and the file is returned unfiled, costing you days against the statute of limitations.

A common misconception is that SSN privacy means you can leave it blank. The form is statutorily required to collect it, but EAMS auto-redacts SSNs on public copies.

Box 3: Occupation at Time of Injury

Box 3 asks what job you were doing when you got hurt. Use the title that matches your last paystub.

Write a specific title: Warehouse Forklift Operator, not Worker. Specificity drives the DWC occupational code and your indemnity rate.

If you held two jobs, list the one where the injury occurred and add a sentence in Box 14 about concurrent earnings under Labor Code §4453(b).

A common mistake is writing General Labor. Judges cannot calculate a permanent-disability rating from a vague title, and your case stalls at the rating string.

A common misconception is that occupation must match what is on your tax return. It must match what you were actually doing for that employer on the date of injury.

Box 4: Date of Injury

Box 4 is where many cases die. Write the date in MM/DD/YYYY format.

For a specific injury, use the date of the accident: 11/02/2025. For a cumulative trauma, use the date you first knew the injury was work-related under Labor Code §5412, which is usually the date a doctor first told you so.

If you cannot pin down the CT date, use the last day worked in that job and check the box marked CT if your form version includes it; otherwise write CT through 11/02/2025 in the margin.

A common mistake is using the date you reported the injury rather than the date of injury itself. The statute of limitations runs from the injury date, not the report date.

A common misconception is that a CT injury has no statute. It does, and §5412 starts the clock the moment you knew or should have known the injury was industrial.

Box 5: Body Parts Injured

Box 5 asks what parts of your body were hurt. List every part, even ones that seem minor.

Use plain English plus the DWC body-part code where you can: Lower back (code 420), Left knee (code 360), Sleep disorder (code 850).

For psychiatric injuries, also list Psyche (code 900) and be ready to meet the Labor Code §3208.3 six-month employment threshold.

A common mistake is listing only the worst body part. Anything not listed here can be barred later under the doctrine of issue preclusion, costing you treatment for that part forever.

A common misconception is that adding more body parts looks greedy. It does not; judges expect a complete list, and you can drop parts later if medical evidence does not support them.

Box 6: How the Injury Occurred

Box 6 wants a one-to-three sentence description of the mechanism of injury. Stick to facts.

Write present-tense, active voice: Applicant lifted a 70-pound box from a pallet, felt a pop in the lower back, and fell to one knee.

If the injury was cumulative, describe the repetitive motion: Applicant performed approximately 1,200 keystrokes per hour over six years, leading to bilateral carpal tunnel.

A common mistake is writing legal conclusions like Employer was negligent. Workers’ comp is no-fault, and conclusions invite a 4906(g) sanctions motion.

A common misconception is that this box must match the DWC-1 word for word. It should be consistent, but you can add detail learned after the DWC-1 was filed.

Box 7: Employer’s Name and Address

Box 7 captures the employer’s exact legal name at the top and its address below. Pull this from your W-2 or paystub, not the sign on the building.

Write it as it appears on payroll records: ACME LOGISTICS, INC. dba ACME WAREHOUSE, 1500 Industrial Way, Fontana, CA 92335.

If your employer is a staffing agency, list both the agency and the host employer; both can be dual employers under Labor Code §3602.

A common mistake is writing only the DBA. Service on a DBA without the legal entity is void, and the case can be set aside up to a year later.

A common misconception is that the WCAB will look up the legal name for you. It will not; intake clerks file what you write.

Box 8: Insurance Carrier (and Claims Administrator)

Box 8 asks for the insurance carrier that wrote the policy and, on a separate line, the claims administrator handling the file. They are often different companies.

Get both names from your DWC-1 acknowledgment letter or the WCIRB coverage search. Write them like this: Carrier: State Compensation Insurance Fund. Claims Administrator: Sedgwick Claims Management Services.

If your employer is self-insured or legally uninsured, write Self-Insured or Uninsured, and the case will route to the Uninsured Employers Benefits Trust Fund (UEBTF).

A common mistake is naming only the third-party administrator. The carrier carries the policy and must be served, or any judgment can be voided.

A common misconception is that the carrier and administrator are interchangeable. They are not; only the carrier is the indemnitor under California insurance law.

Box 9: Wage at Time of Injury

Box 9 asks for your average weekly wage (AWW) on the date of injury. This drives every dollar you receive.

Write a specific number: $1,148.50 per week. Calculate by averaging the 52 weeks before injury, including overtime, bonuses, and the value of housing under Labor Code §4453.

If you worked less than a year, use the actual weeks worked. If you had concurrent jobs, add wages from both employers under §4453(b).

A common mistake is writing the hourly rate. Box 9 is weekly, and the wrong number can shave thousands off your indemnity.

A common misconception is that tips and bonuses do not count. They do, as long as they were regular and reportable.

Box 10: Disputed Issues (Check All That Apply)

Box 10 lists the issues you want the judge to decide. Check every box that could apply, even if you are not sure yet.

Typical checked boxes include Injury AOE/COE, Temporary Disability, Permanent Disability, Medical Treatment, Future Medical, Mileage, Penalties, and Attorney’s Fees.

If your form lists Other, write a one-line description: Other: §132a discrimination, citing Labor Code §132a.

A common mistake is checking only the issue currently disputed. Unchecked issues may be deemed waived at the Mandatory Settlement Conference.

A common misconception is that checking more boxes annoys the judge. Judges expect a full list; narrowing happens at the MSC, not at filing.

Box 11: Venue (WCAB District Office)

Box 11 asks which of the 24 WCAB district offices should hear your case. Venue is governed by Labor Code §5501.5.

You may pick the county where the injury occurred, the county where you live, or the county where your attorney’s principal office sits. Write the office name: Van Nuys District Office.

If you have no attorney and live in a different county than where you were hurt, choose the office most convenient to you; travel costs to hearings come out of your pocket.

A common mistake is choosing the county where the employer is headquartered. That is not a permitted venue under §5501.5 and the defense can file a Petition for Change of Venue.

A common misconception is that venue cannot be changed. It can, but only by motion and order, and you may lose months waiting for a ruling.

Box 12: Attorney Information (If Represented)

Box 12 captures your attorney’s name, State Bar number, firm, address, phone, and email. Leave it blank if you are pro se.

Write it like this: David Kim, SBN 234567, Kim & Associates, 800 Wilshire Blvd., Suite 1200, Los Angeles, CA 90017, (213) 555-0142, dkim@kimlaw.com. The State Bar number is mandatory under 8 CCR §10774.

If you change attorneys later, file a Substitution of Attorney; do not just cross out and rewrite Box 12.

A common mistake is listing a paralegal as the attorney of record. Only a licensed attorney or the worker pro se can sign as the representative.

A common misconception is that signing a fee agreement automatically updates Box 12. It does not; the attorney must file a Notice of Representation.

Box 13: Signature, Date, and Verification

Box 13 is the verification under penalty of perjury required by Code of Civil Procedure §2015.5. Sign in blue ink if filing on paper.

Write your printed name, sign, and date: I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Executed on 11/15/2025, at San Francisco, California. /s/ Maria Lopez.

If you e-file through EAMS, type /s/ Maria Lopez and the system records the verification timestamp.

A common mistake is signing without dating. An undated verification is treated as no verification, and the Application is rejected.

A common misconception is that an attorney can sign for the client. The client must sign, except in death claims where the dependent signs.

Box 14: Additional Information

Box 14 is the catch-all field. Use it for concurrent employment, prior injuries to the same body part, language interpreter requests, and ADA accommodations.

Write short, numbered paragraphs: (1) Applicant requests a Spanish interpreter at all hearings. (2) Applicant had a prior 2018 right-knee injury, Case ADJ1234567, fully resolved by C&R.

If you need a court interpreter, say so here in writing; oral requests at the hearing window can delay your case 30 days.

A common mistake is leaving Box 14 blank when prior injuries exist. Undisclosed priors invite a Petition under Labor Code §4664 for apportionment.

A common misconception is that Box 14 is optional. It is structurally optional, but practically it is where you preserve key rights.

Three Filled-Out Examples Using Real Scenarios

Below are three named filers walking the form end to end. Each table has two columns and at least eight rows.

Scenario 1: Maria Lopez, Warehouse Worker With a Specific Back Injury

Form Section	What Maria Enters
Caption	LOPEZ, MARIA ELENA
Box 1 Address	4421 Mission St., Apt. 3B, San Francisco, CA 94112
Box 2 DOB / SSN	03/14/1985 / 555-12-3456
Box 3 Occupation	Warehouse Forklift Operator
Box 4 Date of Injury	11/02/2025
Box 5 Body Parts	Lower back (420), left knee (360), sleep (850)
Box 7 Employer	ACME LOGISTICS, INC., 1500 Industrial Way, Fontana, CA 92335
Box 8 Carrier	State Compensation Insurance Fund; TPA: Sedgwick
Box 9 AWW	$1,148.50/week
Box 11 Venue	San Bernardino District Office

Scenario 2: James Patel, Office Worker With Cumulative Trauma

Form Section	What James Enters
Caption	PATEL, JAMES ARUN
Box 1 Address	17 Oakwood Ln., San Jose, CA 95123
Box 2 DOB / SSN	07/22/1979 / 555-44-9981
Box 3 Occupation	Senior Software Engineer
Box 4 Date of Injury	CT through 09/30/2025 (per LC §5412)
Box 5 Body Parts	Bilateral wrists (410), neck (110), psyche (900)
Box 6 Mechanism	Repetitive keyboarding ~1,200 keystrokes/hour over 8 years
Box 7 Employer	NORTHGATE TECH CORP., 200 Tech Park Dr., San Jose, CA 95110
Box 8 Carrier	Travelers Indemnity; TPA: Gallagher Bassett
Box 11 Venue	San Jose District Office

Scenario 3: Rosa Hernandez, Surviving Spouse Filing a Death Claim

Form Section	What Rosa Enters
Caption	HERNANDEZ, MIGUEL (DECEASED) by ROSA HERNANDEZ, surviving spouse
Box 1 Address	882 Alvarado St., Los Angeles, CA 90057
Box 2 DOB / SSN	Decedent: 05/10/1972 / 555-77-1212
Box 3 Occupation	Roofer
Box 4 Date of Injury	Date of death 02/14/2026
Box 5 Body Parts	Fatal head trauma (110)
Box 6 Mechanism	Decedent fell 22 feet from a residential roof
Box 7 Employer	VALLEY ROOFING LLC, 4400 Vineland Ave., North Hollywood, CA 91602
Box 8 Carrier	Berkshire Hathaway Homestate; TPA: Intercare
Box 10 Issues	Death benefits, burial expenses, dependency
Box 11 Venue	Van Nuys District Office
Box 14	Filing under LC §5406 within one year of death

Other named filers worth knowing: Aisha Brown, a hospital nurse with a needlestick exposure claim; Marcus Reyes, a police officer with a presumptive heart claim under Labor Code §3212; and Janet Wu, a lien claimant chiropractor filing to collect on unpaid bills.

How to File the Completed Form

You have four channels. Pick one and follow its rules exactly.

EAMS E-Filing (Trial Attorneys & Self-Represented). Upload through the EAMS public portal at no cost. Accepted formats are PDF only, fewer than 25 MB per document. Processing time is 3 to 5 business days, and your proof of filing is the EAMS Case Number assigned by email.

JET File (High-Volume Filers). Use an approved JET vendor. Vendor fees vary; the WCAB charges nothing. Processing is overnight, and proof of filing is the JET acknowledgment XML the vendor returns.

In Person. Walk the original plus one copy to any of the 24 WCAB district offices. No filing fee. Bring a self-addressed stamped envelope so the clerk can mail your conformed copy back. Same-day filing.

By Mail. Send the original, one copy, and a self-addressed stamped envelope to the chosen district office. No fee. Use certified mail, return receipt requested, so the green card is your proof. Processing 7 to 10 business days.

Every channel requires a completed Document Cover Sheet (DWC-CA Form 10232.1) and Document Separator Sheets between attachments, plus a Proof of Service on every defendant.

What Happens After You File

Within roughly 10 business days, the WCAB issues a Notice of Case Opening with your ADJ case number (e.g., ADJ19384756). Save this number; it controls every future filing.

Defendants must answer within 10 days of service under 8 CCR §10510, or risk a default. The first scheduled hearing is usually a Mandatory Settlement Conference (MSC) 90 to 180 days out.

If your case does not resolve at the MSC, it moves to trial before a Workers’ Compensation Administrative Law Judge. Trials are bench trials; no juries. Most decisions issue within 30 to 90 days of submission under Labor Code §5313.

Either party can appeal by filing a Petition for Reconsideration within 20 days of the decision under Labor Code §5903. Missing that deadline makes the award final and unappealable.

Mistakes to Avoid When Filling Out the Form

• Wrong date-of-injury format. Writing Nov 2, 2025 instead of 11/02/2025 causes EAMS optical-character rejection.
• Listing only a DBA in Box 7. Service is void, and the case can be vacated up to one year later.
• Skipping the SSN. EAMS will not assign an ADJ number, and your filing date does not lock in.
• Choosing improper venue. Triggers a defense motion and 60-to-90-day delay.
• Leaving Box 5 incomplete. Body parts not listed can be barred under issue preclusion.
• Vague occupation. Stalls the permanent-disability rating string.
• Wrong AWW. Underpays your indemnity by hundreds per week.
• Unsigned verification. Treated as no verification; Application rejected.
• No Proof of Service. Defendants are not on notice, and no hearing is set.
• Filing past the §5405 statute. Your claim is permanently barred.
• Mixing up carrier and TPA. Judgment can be voided for naming the wrong indemnitor.
• Using an obsolete revision. EAMS bounces forms older than the 1/2017 revision.

Do’s and Don’ts

Do’s:

• Do use the current 1/2017 revision so the barcodes scan correctly in EAMS.
• Do list every body part to preserve future medical for each one.
• Do verify the employer’s legal name through the California Secretary of State before filing.
• Do request an interpreter in Box 14 to avoid 30-day continuances.
• Do save your filed copy as the foundation for every later petition.
• Do calendar your statute deadlines the day you fill out Box 4.

Don’ts:

• Don’t use white-out because EAMS rejects altered fields; reprint the page instead.
• Don’t sign without dating because the verification is invalid.
• Don’t pick venue based on convenience alone if §5501.5 does not allow it.
• Don’t list the TPA as the carrier because the wrong indemnitor voids judgments.
• Don’t write legal conclusions in Box 6 because they invite sanctions.
• Don’t forget the Proof of Service because no service means no jurisdiction.

Pros and Cons of Filing on Your Own vs. With an Attorney

Pros of pro se filing:

• No attorney fee of 9 to 15 percent of your settlement under Labor Code §4906.
• Direct access to free help from the Information & Assistance Officer.
• Faster initial filing because you do not wait for an attorney to take the case.
• Full control over every strategic decision.
• Useful for simple claims where AOE/COE is admitted.

Cons of pro se filing:

• High risk of missing a §5405 or §5412 deadline.
• No leverage at the MSC against an experienced defense attorney.
• Difficulty obtaining QME panels without proper QME process timing.
• Permanent-disability rating disputes require expert cross-examination.
• §132a and serious-and-willful claims demand specialized pleading.

Filing by Mail vs. EAMS E-Filing

Factor	Mail vs. EAMS
Cost	Both free; mail adds postage
Processing Time	Mail 7-10 days; EAMS 3-5 days
Proof of Filing	Certified-mail green card vs. EAMS email
Error Correction	Mail requires re-filing; EAMS allows quick re-upload
Attachments	Mail accepts paper originals; EAMS requires PDF under 25 MB
Best For	One-time pro se filers; high-volume attorneys

FAQs

Do I need to file a DWC-1 before the DWC-AD 1?

Yes. The DWC-1 Claim Form goes to the employer first; the DWC-AD 1 then opens the WCAB case file when a dispute arises.

Is there a filing fee for the DWC-AD 1?

No. California charges no fee to file the Application for Adjudication, in person, by mail, or through EAMS, under WCAB rules.

What is the deadline to file?

Yes, deadlines apply: one year from injury under §5405, one year from death under §5406, and the §5412 trigger date for cumulative trauma.

Can I e-file as a pro se worker?

Yes. The EAMS public portal accepts pro se uploads at no cost; you receive an ADJ number by email.

Do I write my maiden name or married name in the caption?

Yes, write the name on your current ID, and add the former name in parentheses if your DWC-1 was filed under it.

What if I don’t know my AWW for Box 9?

Yes, you must still write a good-faith estimate; you can amend later by filing a Petition to Amend the Application.

Do I list the TPA or the carrier in Box 8?

Yes, list both: the carrier on the first line and the third-party administrator on the second line, because both must be served.

Can I list more than one employer in Box 7?

Yes, list every employer that may be liable, including staffing agencies and host employers under Labor Code §3602.

Do I need to attach medical reports at filing?

No, attachments are optional at filing, but supporting reports speed the first MSC and help judges evaluate disputed issues.

Can I change the WCAB district office later?

Yes, by filing a Petition for Change of Venue, but the moving party must show good cause under Labor Code §5501.6.

Do I sign Box 13 if I have an attorney?

Yes. The injured worker signs the verification; the attorney signs separately as counsel of record on the Notice of Representation.

What if I miss the one-year statute?

No relief is automatic; only narrow exceptions like estoppel, tolling for minors, or employer failure to post the DWC notice poster may save the claim.

Can a dependent file if the worker died?

Yes. Surviving spouses, minor children, and other dependents file under Labor Code §5406 within one year of death.

Do undocumented workers qualify?

Yes. Labor Code §3351 covers all workers regardless of immigration status, and ITINs are accepted in Box 2.