Workers’ Compensation Claim Checklist

Please note: The workers’ compensation forms provided on this website are for the use of California fairs/fairgrounds only.

Print out and use this checklist to make sure all bases are covered when a fair employee experiences a work-related injury or illness:

Upon notice of the injury or illness, provide the injured/ill employee with a Form DWC-1 “Employee’s Claim for Workers’ Compensation Benefits.” This form should be mailed to the employee’s mailing address within 24 hours of notice of injury/illness if he or she isn’t present.

Direct the injured/ill employee to seek treatment at the employer designated medical facility unless the injured/ill employee has advised you, in writing prior to the injury/illness, of their personally selected physician pursuant to the law. (Please refer to the form located in the pamphlet “Facts about Workers’ Compensation” in your Red Book or check with CFSA.

Complete the “Employer’s Report of Occupational Injury or Illness” (Form 5020). Be sure to enter the date the claim form was given to the injured employee (line #28). Mail it along with the “Supervisor’s Report of Work Injury” (Form WCSR), filled out by the injured/ill employee’s supervisor, to: California Fair Services Authority, Attn: Workers’ Compensation Claims Administrator, P.O. Box 15518, Sacramento, CA 95852-0518.

Complete the OSHA Form 300. You’ll find instructions about how to do this, along with a copy of the form in your fair’s Red Book, refer to Workers’ Compensation, Tab 4.

Report immediately by phone, any serious injury or fatality to CFSA at (916) 263-6172 (after hours: [916] 921-2213), and to Cal/OSHA. A list of Cal/OSHA offices throughout California is in your Red Book (Claims and Loss Reporting Guide) under Workers’ Compensation, Tab 5.

TIMEFRAME:

Form DWC-1 within 24 hours of notice of injury/illness.

Form 5020 and the Supervisors Report (WCSR) within five days of notice of injury/illness.

Cal/OSHA Form 300 within seven working days of notice of injury/illness.

MAIL TO:
Attn: Workers’ Compensation Claims Administrator
California Fair Services Authority
P.O. Box 15518
Sacramento, CA 95852-0518

If you have questions about any of the steps on this claim checklist, contact Cindy Hehner, CFSA’s workers’ compensation claims administrator, at (916) 921-2272.