District of Columbia Workers' Compensation Notice Mandatory

OFFICE OF WORKERS’ COMPENSATION	
4058 MINNESOTA AVENUE, N.E. • WASHINGTON, DC 20019 • (202) 671-1000 • (202) 671-1929 (Fax)	
WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other 
person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially 
related to a claim was provided by the applicant.	
NOTICE OF COMPLIANCE	
TO EMPLOYEES1. You are required by law to report promptly to your employer and the Office of Workers’ Compensation an occupational injury 
or disease, even if you deem it to be minor. Form No. 7 DCWC, Notice of Accidental Injury or Occupational Disease, to be 
obtained from the employer or the Office of Workers’ Compensation, must be used for that purpose. After you have completed 
and signed the form, mail it to the Office of Workers’ Compensation at the above address, and to your employer.
2.  You are entitled, if required, to the services of a physician or hospital of your choice and lost wages. Call (202) 671-1000  or visit 
http:does.dc.gov for information.
3.  You may not sue your employer as a result of a work-related injury or disease by reason of your exclusive remedy under the 
Workers’ Compensation Law.
4.  In order to preserve your right to benefits under the DC Workers’ Compensation Law, you must file a written claim on Form No. 
7A DCWC, Employee’s Claim Application, within one (1) year after your injury, or within one (1) year after the last payment of 
benefits.
5.  If you need information regarding your rights and obligations prescribed by law, you may call your employer first. If you require 
further information, you may call the Office of Workers’ Compensation at (202) 671-1000 or visit http:does.dc.gov
6.  The law gives you the right to legal representation if you so choose.
TO EMPLOYERS 1. You are required to have Workers’ Compensation insurance coverage if you have one (1) or more employees.
2.  You are required to display this poster at each worksite so that it will be of the greatest possible benefit to your employees.
3.  You must file an Employer’s First Report of lnjury or Occupational Disease, Form No. 8 DCWC, with the Office of Workers’ 
Compensation, send a copy to the nearest claim office of your insurer, for all occupational injuries or disease, as soon as 
possible, but no later than ten (10) working days after the date of knowledge thereof.
4.  Your employee must file Form No. 7 DCWC, Employee’s Notice of Accidental Injury or Occupational Disease. Please provide 
your employee with Form No. 7 DCWC and direct them to complete it and return it to you and the Office of Workers’ 
Compensation. Once you have received notice from the employee, you are required to send the employee a notice of his/her 
rights and obligations by certified mail, return receipt requested.
5.  You are required to report to the Office of Workers’ Compensation, and your insurer, any disability of more than three (3) days 
which was not previously reported, as soon as possible, but no later than ten (10) working days after the date of knowledge 
thereof.
6.  You are required to furnish, or cause to be furnished, reasonable medical and hospital services, other remedial care or 
vocational rehabilitation, and various types of disability compensation, to an injured or disabled employee.
7.   You are required to obtain from the insurer identified below a supply of all required Workers’ Compensation Forms, or you may 
download the forms and notice mentioned above at our website http://does.dc.gov .
NOTICE: Violation of the various provisions of the Workers’ Compensation law provides for civil penalties.
The undersigned employer hereby gives notice of compliance with all provisions of the Workers’ Compensation Law and 
Administrative Regulations.
NAME OF INSURANCE COMPANY 
Address: ___________________________________________________________________\
_______________________________________________________________________________________________________________________________\
_______
Phone: __________________________________________________________________\
________________
NAME OF EMPLOYER
Address   __________________________________________________________________\
____________________________________________________________ Phone: __________________________________________________________
Employer Representative:______________________________________________________________________\
_____________________________________________________________________________________________________
________________________________________________________________________\
_______________________________________________
Employer ID Number (if number unknown, employer to request from IRS)	
THIS NOTICE IS TO BE POSTED CONSPICUOUSLY IN 
AND ABOUT THE EMPLOYER’S PLACE(S) OF BUSINESS	
FORM NO. 1 DCWC  
Revised June, 2016
LABOR STANDARDS BUREAU
 Department of Employment Services