Workers' Compensation
- Overview
- What to Report
- When to Report
- How to Report
- Medical Treatment
- Temporary Disability
- Report Fraud
How to Report an Industrial Injury
When the employer receives notice, in any form, that an industrial injury has occurred, the following should be done:
A. Employee's Claim For Workers' Compensation Benefits (DWC-1)
Administrative Rule 10119, requires the employer to provide to the employee the "Employee's Clam For Workers' Compensation Benefits" within one working day of the employer receiving notice of knowledge of an industrial injury which results in lost time from work beyond the date of injury or which results in medical treatment beyond first aid (L.C. U5401). The "Employer's Claim For Workers' Compensation Benefits" is also referred to as the "Claim Form".
The procedure for properly administering the Claim Form is as follows:
1. The Employer provides the Claim Form to the employee.
Within one working day of receiving notice or knowledge of an industrial injury the employer must provide the Claim Form to the employee. Failure to provide the Claim Form within 24 hours of the employee's request for the claim form, may result in a penalty up to $5,000.00 (A.D. Rule 10108 (d) (4)).
If the Claim Form is not personally delivered to the employee, a cover letter should be sent to the employee providing them with the Claim Form. The cover letter will serve to prove that the Claim Form was provided to the employee.
2. The Employee Completes the Top Part of the Claim Form.
After completing the top part of the Claim Form, the employee should retain the green copy entitled "Employee's Temporary Receipt" for their records.
3. The Employee Files the Claim Form with the Employer.
This is accomplised when the claim form is personally delivered to the employer, mailed to the employer by registered mail with the return receipt requested, or upon receipt of the employer's knowledge when mailed to the employer by first class mail.
4. The Employer Completes Bottom Part of the Claim Form.
The most important item the employer must fill out is the date the employer received the claim form from the employee, and the name and title of the person who received the claim form. Failure to put the date the Claim Form was received from the employee, may result in a penalty up to $100.00 for each occurrence. (A.D. Rule 10108 (a) (3))
5. The Employer Distributes copies to the Employee and WCA.
The employer provides the employee with the pink copy marked "Employee's Copy" and sends the yellow copy marked "Insurer/Claims Administrator" to Workers' Compensation Administrators. Keep the copy marked "Employer Copy" for your records.
It is recommended that the "Employee's Copy" be sent to the employee with a cover letter. This will help prove that the conirmed copy of the Claim Form was provided to the employee.
If the employee does not return the Claim Form to the employer, the employee will be precluded from receiving any late penalty that may be due and will be precluded from pursuing further legal remedies. It should be noted that even if the employee does not file the Claim Form, the employer is still obligated to provide benefits in a timely manner to the injured worker. (A.D. Rule 10116.1)
B. Complete the "Employer's Report of Injury" (Form 5020).
Upon notice of an industrial injury, the employer should immediately complete the "Employer's Report of Occupational Injury or Illness" form which is also known as the "Employer's Report" or the "5020". This form is required by section 14001 Title 8 and is ONLY a report of the injury and is not an admission of liability and cannot be used against the employer as evidence. Section 14001 requires the form to be filled out within five days after the injury or illness has been reported to the employer.
Section 1A of the "Employer's Report of Injury" should be left blank since there is no policy number because you are self-insured.
Sections 29, 30, 30B, 34 and 35 of the "Employer's Report of Injury" should be filled out very carefully. The answers provided in these boxes will give WCA an indication of whether the claim should be accepted, delayed, or denied. These answers will also help us determine whether there is a subrogation potential against a negligent third party.
The Form should be filled out in triplicate with one copy going to the employer, another to WCA and the original to:
Workers' Compensation Administrators
Donovan St.
Santa Maria, CA 93454
Again, the "Employer's Report of Injury" form should be filled out as soon as notice of an industrial injury is received and sent to WCA. Do not wait for a report from the doctor or receipt of the Claim Form from the employee.
C. Questionable Injuries
If you are concerned regarding whether a claim should be covered by workers' compensation, put your concerns in writing and send it to WCA.
1. Give "Facts for Injured Workers" pamphlet to Injured Employee.
When an industrially injured employee reports an injury, give them the pamphlet entitled "Facts for Injured Workers" (red pamphlet).
Section 9882 of the Administrative Rules requires the employer upon receiving knowledge of an injury to an employee, to advise the employee within 5 days of their workers' compensation benefits. The "Facts for Injured Workers" pamphlet serves this purpose.
2. Serious Injury or Death.
In the event an employee suffers an industrial injury that is serious or results in death, notify Workers' Compensation Administrators immediately by telephone.
The employer/representative is required to notify the nearest district office of the California Division of Occupational Safety and Health when an industrial injury is serious or results in death.