California Forms
9 State Forms found
| name | number | revision | print or send online | |
|---|---|---|---|---|
DOCTOR'S FIRST REPORT OF OCCUPATIONAL INJURY OR ILLNESS |
Form 5021 | (Rev. 5) 10/2015 | ||
EMPLOYER'S REPORT OF OCCUPATIONAL INJURY OR ILLNESS |
FORM 5020 | (Rev7) June 2002 | ||
Workers Compensation Claim Form DWC 1 and Notice of Potential Eligibility |
DWC 1 | Rev. 1/1/2016 | ||
THIRD PARTY COMPROMISE AND RELEASE |
DWC-CA form 10214 (e) | REV. 11/2008 | ||
Notice to Employees - Injuries Caused By Work |
DWC 7 | 1/1/2016 | ||
Basic Facts on Workers' Compensation for Injured Workers |
No Form Number | July 2010 | ||
UN FOLLETO PARA EL NUEVO EMPLEADO |
No Form Number | Julio 2014 | ||
Time of Hire Pamphlet |
No Form Number | July 2014 | ||
NOTICE OF OFFER OF REGULAR, MODIFIED, OR ALTERNATIVE WORK FOR INJURIES OCCURRING ON OR AFTER 1/1/13 DWC - AD 10133.35 |
DWC-AD form 10133.35 (SJDB) | EFF: 1/1/14 | ||
Disclaimer: These forms may not be the most recent version. California may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on this site. Please check official sources.
California Contacts
| name | title/position | phone/email/web |
|---|---|---|
Division of Workers Compensation |
N/A |
800-736-7401 http://www.dir.ca.gov/wcab/wcab.htm |
Department of Insurance |
N/A |
510-622-2660 http://www.dir.ca.gov/iwc/iwc.html |
Department of Industrial Relations |
N/A |
213-897-5267 http://www.dir.ca.gov/sip/sip.html |
Michael Wimberly |
Executive Officer |
916-274-5751 oshappeals@dir.ca.gov |
Jamie Meyers |
Supervisor (Headquarters) |
916-574-0300 jlmeyers@dir.ca.gov |
Lyn Asio |
Supervisor (Northern California Audit Team) |
916-574-0300 lasio@dir.ca.gov |
Marilee Robinson |
Supervisor (Southern California Audit Team) |
916-574-0300 mrobinson@dir.ca.gov |
Art Carter |
Chairperson, Labor Member |
916-274-5751 oshappeals@dir.ca.gov |
California Insurance Requirements
State Fund and Self-Insurance Information |
||
| State Fund? | ||
| Injured worker claim form? | ||
| Basis of the state WC medical fee schedule | ||
| Basic fee schedule reimbursement provisions | ||
| General medical benefit provisions | ||
| Report an injury/illness claim | ||
| General medical benefit limitations | ||
| Private Insurance Carriers? | ||
| Self-insurance - Individual Employers? | ||
| State has a Medical Fee Schedule? | ||
| Self-insurance - Groups of Employers/Pools? | ||
Insurance Requirements for Workers' Compensation |
||
| Injured worker claim form for death benefits? | ||
| Insurance Compulsory or Elective? | ||
| Form for injured worker to revoke prior rejection workers' compensation? | ||
| Penalties/fines/assessments for not carrying workers' compensation insurance? | ||
| Class of penalty/offense/crime is applicable for not having insurance | ||
| Waivers Permitted? | ||
| Form for injured worker to reject terms of workers' compensation? | ||
| Numerical Exemptions? | ||
| Workers' compensation medical E-Bill Requirements? | ||
| Exemptions for Private Employers? | ||
| Exemptions for Public Entities? | ||
| Special Coverage Provisions? | ||
| Injured worker assistance on the Web or a State Hotline Ombudsman? | ||
Coverage for Agricultural and Domestic Workers |
||
| Required for Agricultural workers? | ||
| Home page on State Web site for the Injured Worker? | ||
| Exceptions for Agricultural Employees? | ||
| State FAQ Sheet for Injured Worker? | ||
| Required for Domestic workers? | ||
| Coverage for Domestic Workers voluntary? | ||
| State explanation of claim process available for Injured Worker? | ||
| Can Domestic Workers be specifically excluded? | ||
| Coverage for Agric/Domestic workers the same as for other employees? | ||
Misc. State Insurance Information |
||
| Drug Free Workplace and/or Testing Policies? | ||
| Special provisions for providing workers' comp to volunteer firefighters? | ||
| Special provisions for death benefits for volunteer firefighters? | ||
Coverage for Minors |
||
| Minors covered by workers' compensation insurance? | ||
California Compensation Laws
Waiting Periods |
||
| Waiting period for indemnity (loss wages) | ||
| Retroactive Period | ||
Minimum and Maximum Indemnity Benefits |
||
| Weekly PPD Min/Max Benefits | ||
| Weekly PTD Min/Max Benefits | ||
| Weekly TTD Min/Max Benefits | ||
| Weekly TPD Min/Max Benefits | ||
Death Benefits |
||
| Weekly Min/Max Death Benefits | ||
| Time Limits for Death Benefits | ||
| Compensation limits for surviving spouse and child(ren) | ||
| Maximum Burial Allowances for a death claim | ||
| Effective Date for these Benefits | ||
Maximum Compensation Adjustment Dates and Percentages for Indemnity |
||
| Adjustment date for the maximum compensation | ||
| Min/Max percentage of SAMW or SAWW | ||
| Percentage of wages used to calculate the benefit rate | ||
| Offsets for Temporary Disability? | ||
Method of Payment for Disability Awards |
||
| Scheduled awards paid in addition to TTD benefits? | ||
| Scheduled awards paid upon termination of TTD benefits? | ||
| Scheduled awards reduced because of receipt of TTD benefits? | ||
Benefits for Permanent Disfigurement |
||
| Nature of Disfigurement Policy | ||
| Compensation received | ||
| Maximum Period | ||
Misc. State Compensation Information |
||
| Method of payment of compensation | ||
| Mileage reimbursement rate for injured workers | ||
Compensation for Minors |
||
| Future earning capacity of minor worker considered? | ||
| Special benefit provisions for minor workers? | ||
Second/Special Injury Fund |
||
| Second/Special Injury Fund? | ||
| Portion payable by the employer? | ||
| Portion payable by the fund? | ||
| Source of the Fund | ||
California Medical Guidelines
Physician Selection |
||
| Employee make Initial choice for a Physician? | ||
| Employee required to select a Physician from a list prepared by a State Agency? | ||
| Employee required to select a Physician from a list maintained by the Employer? | ||
| Employer select the Physician (direct where the Employee must go)? | ||
| State Agency change the Employer's Initial Physician Selection? | ||
| Employee have free choice after a specified period of time? | ||
Misc. Medical Policies |
||
| Full medical benefits provided under state workers' compensation system? | ||
| Permissible to settle Medical Benefits under workers' compensation system? | ||
| Offset provisions under the State's workers' compensation system? | ||
| Medicare Offsets? | ||
| Artificial appliances covered? | ||
| Prayer and/or spiritual treatment covered? | ||
California Admin/Reporting
First Report of Injury Form Information |
||
| State's First Report of Injury form | ||
| Number of the form (if applicable) | ||
| Revision date of the First Report of Injury form | ||
| Which State Agency administers workers' comp claims? | ||
First Report Submission Requirements and Preferences |
||
| State's Preferred Method for receiving the First Report | ||
| State accepts claims via EDI? | ||
| State accepts claims via Email? | ||
| State accepts claims via FAX? | ||
| State accepts claims via Online? | ||
| State accepts claims via US Mail? | ||
Reporting Requirements |
||
| Types of Injuries/Accidents the Employer is required to report | ||
| Injuries/Illnesses not covered? | ||
| Date the State requires the First Report to be submitted | ||
| Time Requirement for the Injured Worker to File a Claim | ||
| Employer Required to Keep Records of Claims? | ||
Penalties |
||
| Monetary Penalties for Failure to Report? | ||
| Imprisonment Penalties for Failure to Report? | ||
Vocational Rehabilitation and Return to Work Policies |
||
| Rehab Services are Provided by the State | ||
| Employer/Carrier Responsibilities for Voc Rehab | ||
| Employee's responsibilities regarding Voc Rehab | ||
| Penalties to the Employee for non-compliance | ||
| Employee's benefits during Voc Rehab | ||
| Services are provided by the State WC Rehab Unit | ||
| State's Codes/Regulations for Voc Rehab | ||
| Funding source for the rehabilitation of disabled workers | ||
| Maintenance Allowance Benefits provided during rehabilitation of Disabled Workers? | ||
Fraud Provisions |
||
| Does the State have a Fraud Bureau? | ||
| Claim Fraud defined as a specific crime? | ||
| Underwriting Fraud a specific crime | ||
| Insurer Fraud a specific crime? | ||
| Fraud Plan required? | ||
| SIU required? | ||
| Annual Fraud Reports required? | ||
| Fraud Warning required? | ||
| Fraud provisions for Insurer-to-Insurer fraud? | ||
| Notify the Licensing Board? | ||
Immunity Provisions |
||
| Specific Immunity for Insurer to Insurer? | ||
| Specific Immunity for reporting to Law Enforcement? | ||
| Specific Immunity for reporting to the Fraud Bureau? | ||
| Specific Immunity for reporting to the NAIC? | ||
| Specific Immunity for reporting to the NICB? | ||
Subrogation Statutes and Provisions |
||
| Carrier sue the Third Party directly? | ||
| Intervention? | ||
| UM/UIM Recovery? | ||
| State's Subrogation Statutes | ||
Medical Malpractice Statutes and Provisions |
||
| Medical Malpractice as a Third Party? | ||
| Legal Malpractice as a Third Party? | ||
| Recovery Limits | ||
| Employer Negligence? | ||
| Future Credit? | ||
| Personal Injury Statute of Limitations | ||
Reporting Requirements and Information for Occupational Diseases |
||
| Occupational Diseases are covered | ||
| Time limit for filing a claim for Occupational Disease | ||
| Medical Care Provisions for Occupational Disease claims | ||
| Compensation Provisions for Occupational Diseases | ||
| Claims settled or resolved | ||
Administration and Appeals Provisions |
||
| Time limit for modifications of award? | ||
| Attorney Fees determined? | ||
| Method for paying Attorney's Fees | ||
| Administrative agency that has purview over appeals provisions | ||
| Time requirement to file an appeal | ||
| Court(s) for Appeals | ||
| Process and procedure for filing an appeal | ||
| Appeal process by way of a Jury Trial? | ||