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Free DWC Application for Adjudication of Claim Template – Download Now!

Download the DWC Application for Adjudication of Claim template for free. Use this form to formally dispute a workers' compensation claim and request a legal hearing.

Free Download

The DWC Application for Adjudication of Claim is a legal form used in workers' compensation cases to formally dispute a claim. If an injured worker and their employer or insurance company cannot agree on a settlement, this application is filed to request a hearing before an administrative law judge.

When to Use This Form

If your workers' compensation claim has been denied or delayed.

When there is a dispute over medical treatment or benefits.

If you need a formal decision on your case from a judge.

What’s Included in the Application?

Injury details (date, type, and circumstances of the injury).

Employer and insurance company information.

Disputed issues, such as unpaid benefits or denied medical care.

Requested compensation and claim details.

What Happens After Filing?

After the form is submitted to the Division of Workers’ Compensation (DWC):

A hearing is scheduled, where both sides present evidence.

A judge reviews the case and makes a final decision.

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