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Form 14-0083 — Information Request

File: 
PDF icon Information Request -- Form 14-0083.pdf
Description: 

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Name

Information Request

Number

14-0083

Effective

July 1, 2023

Overview

You must use this form when requesting public or confidential information from the DWC.

You may request public information, confidential information, or both using this form. DWC will not release information to you until you have paid the appropriate fees for your request.

Correctly completing this form helps expedite DWC's response to your information request.

For more information about requesting information from DWC, click here.

Instructions

To complete the form:

  1. Download the form.
  2. Under the heading "Worker," provide information for the worker about whom you are seeking information.
  3. Under the heading "Employer," provide information for the employer's name, if you know the employer's name.
  4. Under the heading "Workers' Compensation Case(s)," provide the DWC file number(s), if you know them. If known and provided, this information will help expedite processing of your request.
  5. Under the heading "Workers' Compensation Case(s)," provide the alleged date(s) of injury, if you know them. If known and provided, this information will help expedite processing of your request.
  6. Under the heading, "Requestor," provide your information.
  7. Under the heading "Public Information Requested (If Any)," check the box next to each type of public information you are requesting, if any. If you are requesting a type of information not shown, check the box for "Other described below," and describe the other public information you are requesting in the corresponding box below.
  8. Under the heading "Confidential Information Requested (If Any)," check the box next to each type of confidential information you are requesting, if any. If you are requesting a type of information not shown, check the box for "Other described below," and describe the other confidential information you are requesting in the corresponding box below. This section must be completed if you request confidential information or your request will not be processed.
  9. Under heading "Confidential Information Requested (If Any)," the last section allows you to indicate why you may receive the requested confidential information. The most common reasons is that you have a waiver, signed by each person whose confidential information is sought, authorizing release of the requested confidential information to you. If you have such a waiver, you should provide it to DWC with the completed Information Request form. To access the DWC's Authorization to Release Information form, click here.

Information Request Portal

To access the online DWC information request portal, click here.