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Workers' Compensation Claim Checklist: What to Do When an Employee
has a
Work-Related Injury or Illness
Employers: Print out and use this checklist to make sure
all bases are covered when a fair employee suffers an injury or
illness stemming from their employment:
Within 24 hours of notice of the injury or illness, you
must provide the employee with an "Employee'sClaim for Workers'
Compensation Benefits," (DWC 1). If
the employee isn't present, the form should be mailed
to the employee.
Direct the injured/ill employee to seek treatment at the
employer designated medical facility unless the employee
has advised you in writing prior to the injury/illness
of his personally selected physician.
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.
Report immediately by phone, any serious injury
or fatality to CFSA at (916) 263-6172,
and to
Cal-OSHA. (After normal business hours,
contact CFSA at [916] 921-2213.) A
list of Cal-OSHA offices throughout
California is in your Red Book (Claims and Loss Reporting Guide)
under Workers' Compensation, Tab 5.
If you have questions about any of the steps on this claim
checklist, contact Patti
Nevin or Angie Grech.
Claim
Checklist