Employer’s Report of Occupational Injury or Illness
How to Fill Out the Employer’s Report, Form 5020
WITHIN FIVE DAYS of any knowledge of a work-related injury or illness that results in lost time beyond the date of the incident or that requires medical treatment beyond simple first aid:
Step 1. Have an authorized fair representative fill out the Employer’s Report of Occupational Illness or Injury, Form 5020. It’s helpful if you fax or email the form to CFSA to alert the claims team of an incident; however, you must also MAIL a signed copy of the 5020 to CFSA’s Workers’ Compensation administrator along with a signed copy of the Supervisor’s Report. Remember to save copies of both reports for your fair’s files.
A completed, signed Employer’s Report must be in CFSA’s hands within five days of any knowledge of the injury or illness.
NOTE: This form is for use by California’s fairs/fairgrounds ONLY.
Please be as complete as possible and answer all questions. If any of the questions on the form cannot be answered, write “unknown” in the blank.
- Questions 1-6 request special information about the “Employer” – the fair – such as name, address, etc.
- Questions 7 through 29 request specific information about the injury and treatment sought. Several of the questions have an example that will help you formulate a specific explanation. For all employees that earn less than $1,260 per week, include earnings information for one year prior to the date of injury.
- The answer to question 17 is the same date as appears on line 12 of the Employee’s Claim for Workers’ Compensation Benefits (Form DWC-1): Date employer first knew of injury.
- The answer to question 18 is the same date that appears on line 13 of the Employee’s Claim for Workers’ Compensation Benefits, DWC-1: Date claim form was provided to employee.
- Questions 30 through 39 ask for information about the injured employee. When answering question 37A, indicate employment status as full-time, temporary, fairtime, alternate work program/community service, volunteer or 119-day employee. Under no circumstances would a fair worker be considered “seasonal.” Fairtime employees are considered to be “temporary.”
Step 2. Mail signed originals of both the Employer’s Report (Form 5020) and the Supervisor’s Report to: CFSA, P.O. Box 15518, Sacramento, CA 95852
In addition to the mandatory copy mailed to CFSA, it’s helpful if you also fax or email a copy of the Employer’s Report to CFSA to alert the claims team of an incident. This way, if the injured worker or a representative contacts CFSA we will be aware of the incident:
Fax to: (916) 263-6159, attention Cindy Hehner
Email to: Cindy Hehner, CFSA’s Workers’ Compensation claims administrator, at firstname.lastname@example.org.