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Employer's Reporting Requirements:

The Employer's Report of Occupational Injury or Illness (Form 5020).

Every employer is required to file a complete report of every occupational injury or illness to each employee which results in lost time beyond the date of injury or illness or which requires medical treatment beyond first aid*. Lost time means absence from work for a full day or shift beyond the date of the injury or illness (CCR § 14001).

If the employer has filed a report of injury or illness and the employee subsequently dies as a result of the reported injury or illness, the employer is required to file an amended report indicating such death, within five days after the employer is notified or learns of the death.

In the case of insured employers, the report must be filed with the insurer within five days after the insured employer obtains knowledge or the injury, illness or death.

To assure timely filing of the doctor's first report, the employer, upon request of the physician, must immediately disclose the name and address of the employer's workers' compensation insurance provider. In the case of a self-insured employer, the report must be filed directly with the Division of Labor Statistics and Research within five days after the employer obtains knowledge of the injury, illness or death. In addition, the self-insured employer must transmit the doctor's report (Form 5021) to the Division of Labor Statistics and Research within five days of receipt.

If you already have Adobe Acrobat, simply click on the link below to view and print the file.

Click here to download Employers' First Report form for printing


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Employee Claim Form:

Within one working day of receiving notice or knowledge of injury or illness which results in lost time beyond the date of injury or illness or which results in medical treatment beyond first aid*, the employer must provide, personally or by first class mail, a claim form (DWC-1) and a notice of potential eligibility for benefits (NOPE) to the injured employee, or in the case of death, to his or her dependents.A completed Claim Form (DWC-1) must be filed with the employer by the injured employee, or, in the case of death, by a dependent of the injured employee, or by an agent of the employee or dependent.

A dated copy of the completed Claim Form must be provided by the employer to the employer's insurer and to the employee, dependent, or agent who filed the form.

State law requires the claims administrator to authorize medical treatment within one day of the employer's receipt of the claim form, and the employer is liable for up to $10,000 in medical treatment until the claim is accepted or rejected, so as soon as the employee or their representative returns a completed claim form, the employer should report the claim immediately by phone or fax to the claims administrator.

In August 2015, the state approved regulations revising the Notice of Potential Eligibility (NOPE) and DWC-1 claim form, so as of January 1, 2016, the 1/1/16 version of the claim form should be used. CWCI has preprinted and assembled the 6-part DWC-1/Notice of Potential Eligibility Forms (Rev. 1/16) on NCR paper which makes it much easier to complete and process the form (minimum order 100 forms). Order forms are available by calling 510-251-9470, or click here to order online from our Store. Alternatively, those needing just one claim form may click the Adobe Acrobat file below, which contains the DWC-1/NOPE. The 3-page NOPE, should be provided as a cover page attached to the DWC-1 form. If you are not using the pre-printed 6-part form on NCR paper, you will need to make photocopies, as the state requires the employee be given a copy as a temporary receipt after completing the employee section; then after the employer completes their section, they must keep a signed and dated copy, give one to the claims administrator, and give one to the employee.

If you already have Adobe Acrobat, simply click on the link below to view and print the file.

Click here to download a single copy of the Employee Claim Form for printing.

Single copies of claims forms also are available from district offices of the Employment Development Department and the Division of Workers' Compensation.

*First aid is defined as any one-time treatment and any follow-up visit for the purpose of observation of minor scratches, cuts, burns, splinters, or other minor industrial injury, which do not ordinarily require medical care. This one-time treatment, and follow-up visit for the purpose of observation, is considered first aid even though provided by a physician or registered professional personnel.

 

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