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You can now fill out the Employer's
Report (Form 5020) online* as well as on a printed form! Take a look at the easy steps and the deadlines below, and then, if you'd like to fill out the form online, simply click on Employer's Report, Form 5020
*To access the form you will need Adobe Acrobat Reader (minimum) on your computer, available for free downloading from the Adobe
Web site or the full version of Adobe Acrobat Standard or Professional.
To Fill Out the Employer's Report of Occupational Injury or Illness Form (two steps):
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:
1. Have an authorized employer representative fill out the "Employer's Report of Occupational Injury or Illness" (5020 Form) and
then mail it and/or submit it electronically to California Fair Services Authority (CFSA).
a. 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 who earn less than $1,260 per week, include earnings information for
one year prior to the date of injury.
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The answer to question 17 is the same date as appears on line
11 of the "Employee's Claim for Workers' Compensation Benefits,"
DWC-1, Date employer first knew of injury.
- The
answer to question 18 is the same date that appears on line
12 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."
2. After you've completed the form:
If you're using a printed form: Print two copies, one for your files, one to mail to CFSA (P.O. Box 15518, Sacramento, CA 95852). Remember, this completed form must be in CFSA's hands within five days of any knowledge of the injury or illness.
If you're using the online form: Click "PRINT AND SUBMIT" at the bottom of the form to simultaneously
submit it to CFSA and to open the print action window on your computer. In the print window, request two copies ~ an original that you'll sign and mail to CFSA (P.O. Box 15518, Sacramento, CA 95852), and a second copy for your files.
Want to save a copy of the completed online form?
If you have a full version of the Adobe Acrobat software program (not just Acrobat Reader)
on your computer, you can save a copy of the completed 5020 form. To ensure that
the form opens with your Acrobat program (so that you are able to save it), you’ll need to check your Acrobat “Preferences” settings. Here's how:
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Open Adobe Acrobat.
Click on “Edit” in the main menu bar and then click on “Preferences” in the “Edit” menu.
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In the “Preferences” window, click on “Internet” in the left hand “Categories” column. If the boxes for “Display PDF in browser”, “Allow fast Web view”, and “Allow speculative downloading in the background” aren’t checked, do so by clicking each box with
your mouse.
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Click “OK” to close the “Preferences” window.
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Close Acrobat. The next time you open the 5020 PDF form from CFSA’s Web site, it will automatically
open in Adobe Acrobat and you can save the form just as you would save any other
PDF document.
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Employer's
Report