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 & Notice of Potential Eligibility

DWC 1 Rev. 1/1/2016

Basic Facts on Workers' Compensation for Injured Workers

No Form Number July 2010

Time of Hire Pamphlet

No Form Number July 2014

Un Folleto para el Nuevo Empleado

No Form Number Julio 2014

Notice to Employees - Injuries Caused By Work

DWC 7 1/1/2016

Third Party Compromise and Release

DWC-CA form 10214 (e) REV. 11/2008

Notice of Offer of Regular, Modified, or Alternative Work

DWC-AD form 10133.35 (SJDB) EFF: 1/1/14
More State Forms

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
More State Contacts

California Insurance Requirements

State Fund and Self-Insurance Information

State Fund?
Yes
General medical benefit provisions
Full medical benefits with some limitations
Private Insurance Carriers?
Yes
Report an injury/illness claim
Must be in writing
General medical benefit limitations
Chiropractic physical therapy & occup...(show more)
Chiropractic physical therapy & occupational therapy visits limited to 24 per specialty. Insurer may authorize additional visits. (show less)
Self-insurance - Individual Employers?
Yes
State has a Medical Fee Schedule?
Yes
Self-insurance - Groups of Employers/Pools?
Yes
Basis of the state WC medical fee schedule
Relative Value Scale

Insurance Requirements for Workers' Compensation

Injured worker claim form?
Yes
Basic fee schedule reimbursement provisions
MRA
Insurance Compulsory or Elective?
Compulsory
Injured worker claim form for death benefits?
Yes
Workers' compensation medical E-Bill Requirements?
Yes
Penalties/fines/assessments for not carrying workers' compensation insurance?
Yes
Class of penalty/offense/crime is applicable for not having insurance
Misdemeanor with possible imprisonmen...(show more)
Misdemeanor with possible imprisonment and possible Stop Work Order (show less)
Waivers Permitted?
Yes
Form for injured worker to reject terms of workers' compensation?
Not Applicable
Numerical Exemptions?
No
Form for injured worker to revoke prior rejection workers' compensation?
Not Applicable
Exemptions for Private Employers?
Yes
Exemptions for Public Entities?
Yes
Special Coverage Provisions?
Yes

Coverage for Agricultural and Domestic Workers

Injured worker assistance on the Web or a State Hotline Ombudsman?
Yes
Required for Agricultural workers?
Mandatory
Exceptions for Agricultural Employees?
No
Home page on State Web site for the Injured Worker?
Yes
Required for Domestic workers?
Yes
State FAQ Sheet for Injured Worker?
Yes
Coverage for Domestic Workers voluntary?
No
State explanation of claim process available for Injured Worker?
Yes
Can Domestic Workers be specifically excluded?
No
Coverage for Agric/Domestic workers the same as for other employees?
Yes

Misc. State Insurance Information

Drug Free Workplace and/or Testing Policies?
Yes
Special provisions for providing workers' comp to volunteer firefighters?
Yes
Special provisions for death benefits for volunteer firefighters?
Yes

Coverage for Minors

Minors covered by workers' compensation insurance?
Yes
More State Insurance Requirements

California Compensation Laws

Waiting Periods

Waiting period for indemnity (loss wages)
3 days
Retroactive Period
14 days

Minimum and Maximum Indemnity Benefits

Weekly PPD Min/Max Benefits
$160.00 / $290.00
Weekly PTD Min/Max Benefits
$175.88 / $1,172.63
Weekly TTD Min/Max Benefits
$175.88 / $1,172.63
Weekly TPD Min/Max Benefits
$175.88 / $1,172.63

Death Benefits

Weekly Min/Max Death Benefits
$224.00 / $1,103.79
Time Limits for Death Benefits
One year and Specific time limit for ...(show more)
One year and Specific time limit for children based on age (show less)
Compensation limits for surviving spouse and child(ren)
$320,000 for spouse. $250,000 for children.
Maximum Burial Allowances for a death claim
$10,000
Effective Date for these Benefits
01-01-16

Maximum Compensation Adjustment Dates and Percentages for Indemnity

Adjustment date for the maximum compensation
January 1st of each year...
Min/Max percentage of SAMW or SAWW
Not applicable
Percentage of wages used to calculate the benefit rate
66 2/3
Offsets for Temporary Disability?
Yes

Method of Payment for Disability Awards

Scheduled awards paid in addition to TTD benefits?
Yes
Scheduled awards paid upon termination of TTD benefits?
Yes
Scheduled awards reduced because of receipt of TTD benefits?
No

Benefits for Permanent Disfigurement

Nature of Disfigurement Policy
Disfigurement of face due to scarring...(show more)
Disfigurement of face due to scarring or deformity (show less)
Compensation received
No set figure
Maximum Period
No maximum period specified

Misc. State Compensation Information

Method of payment of compensation
Direct Payment
Mileage reimbursement rate for injured workers
.535

Compensation for Minors

Future earning capacity of minor worker considered?
Subject to consideration
Special benefit provisions for minor workers?
Yes

Second/Special Injury Fund

Second/Special Injury Fund?
Yes
Portion payable by the employer?
Disability caused by second injury
Portion payable by the fund?
Difference between compensation payab...(show more)
Difference between compensation payable for second injury and permanent disability (show less)
Source of the Fund
$125,000 in each no-dependency death ...(show more)
$125,000 in each no-dependency death case or unpaid balance. Funds are also received from the employer-paid Subsequent Injuries Benefits Trust Fund Assessment. (show less)
More State Compensation Laws

California Medical Guidelines

Physician Selection

Employee make Initial choice for a Physician?
Yes, with conditions. See "more i...(show more)
Yes, with conditions. See "more info." (show less)
Employee required to select a Physician from a list prepared by a State Agency?
No
Employee required to select a Physician from a list maintained by the Employer?
No
Employer select the Physician (direct where the Employee must go)?
No
State Agency change the Employer's Initial Physician Selection?
No
Employee have free choice after a specified period of time?
Yes

Misc. Medical Policies

Full medical benefits provided under state workers' compensation system?
No
Permissible to settle Medical Benefits under workers' compensation system?
Yes
Offset provisions under the State's workers' compensation system?
Yes
Medicare Offsets?
Yes
Artificial appliances covered?
Yes
Prayer and/or spiritual treatment covered?
No
More State Medical Guidelines

California Admin/Reporting

First Report of Injury Form Information

State's First Report of Injury form
Employer's Report of Occupational...(show more)
Employer's Report of Occupational Injury or Illness (show less)
Number of the form (if applicable)
DLSR 5020
Revision date of the First Report of Injury form
06-02-11
Which State Agency administers workers' comp claims?
Division of Workers' Compensation

First Report Submission Requirements and Preferences

State's Preferred Method for receiving the First Report
EDI
State accept claims via EDI?
Yes
State accept claims via Email?
No, Discontinued
State accept claims via Online?
No
State accept claims via FAX?
No
State accept claims via US Mail?
No

Reporting Requirements

Types of Injuries/Accidents is the Employer required to report
Death or serious injuries/ Disability...(show more)
Death or serious injuries/ Disability of 1 day or more, other than first aid /Occupational disease or pesticide poisoning (show less)
Injuries/Illnesses not covered?
Injury or Illness not caused by work.
Date the State requires the First Report to be submitted
Within 5 Days
Time Requirement for the Injured Worker to File a Claim
In writing within 30 days; excusable....(show more)
In writing within 30 days; excusable. Within 1 day of receiving notice or having knowledge of injury, employer must provide injured worker with claim form (show less)
Employer Required to Keep Records of Claims?
Yes

Penalties

Monetary Penalties for Failure to Report?
$50 - $200
Imprisonment Penalties for Failure to Report?
Non-specified

Vocational Rehabilitation and Return to Work Policies

Rehab Services are Provided by the State
Physical and Vocational Rehabilitation
Employer/Carrier Responsibilities for Voc Rehab
Section 139.5 Repealed. Cover Voc Reh...(show more)
Section 139.5 Repealed. Cover Voc Rehab costs. During Physical Rehab & Voc Rehab pay TTD & additional living expenses. Mandatory payments generally capped at $16,000. (show less)
Employee's responsibilities regarding Voc Rehab
Employee must request Voc Rehab withi...(show more)
Employee must request Voc Rehab within 5 years of the date of injury. (show less)
Penalties to the Employee for non-compliance
Compensation withheld for refusal to ...(show more)
Compensation withheld for refusal to cooperate (show less)
Employee's benefits during Voc Rehab
Section 139.5 Repealed. TTD or mainte...(show more)
Section 139.5 Repealed. TTD or maintenance allowance at $246 (limited to 52 weeks) and living expenses necessitated by rehabilitation; terminated VR services may be re- stored within 5 years after injury in certain cases. (show less)
Services are provided by the State WC Rehab Unit
Medical
State's Codes/Regulations for Voc Rehab
(Labor Code section 4658.7); Sec. 139...(show more)
(Labor Code section 4658.7); Sec. 139.5 repealed (show less)
Funding source for the rehabilitation of disabled workers
No fund established
Maintenance Allowance Benefits provided during rehabilitation of Disabled Workers?
A new Supplemental Job Displacement B...(show more)
A new Supplemental Job Displacement Benefit (SJDB) program applies to injuries on or after 1/1/04. This is a nontransferable voucher for education-related retraining or skill enhancement, or both, payable to a state-approved or accredited school. To qualify for this benefit, the employee does not return to work within 60 days after temporary disability ends and does not return to modified or alternative work. The maximum voucher amount is $10,000. Under SJDB there is no maintenance allowance. For injuries occurring on or after 1/1/04. (show less)

Fraud Provisions

Does the State have a Fraud Bureau?
Yes
Claim Fraud defined as a specific crime?
Yes
Underwriting Fraud a specific crime
Yes
Insurer Fraud a specific crime?
No
Fraud Plan required?
Yes
SIU required?
Yes
Annual Fraud Reports required?
Yes
Fraud Warning required?
Yes
Fraud provisions for Insurer-to-Insurer fraud?
Yes
Notify the Licensing Board?
Yes

Immunity Provisions

Specific Immunity for Insurer to Insurer?
No
Specific Immunity for reporting to Law Enforcement?
No
Specific Immunity for reporting to the Fraud Bureau?
Yes
Specific Immunity for reporting to the NAIC?
No
Specific Immunity for reporting to the NICB?
No

Subrogation Statutes and Provisions

Carrier sue the Third Party directly?
Yes
Intervention?
Yes
UM/UIM Recovery?
No
State's Subrogation Statutes
Labor Code § 3852

Medical Malpractice Statutes and Provisions

Medical Malpractice as a Third Party?
No
Legal Malpractice as a Third Party?
Undecided
Recovery Limits
Yes
Employer Negligence?
Proportional. Only if Verdict
Future Credit?
Yes
Personal Injury Statute of Limitations
2 Years

Reporting Requirements and Information for Occupational Diseases

Occupational Diseases are covered
All diseases arising out of and in th...(show more)
All diseases arising out of and in the course of employment (show less)
Time limit for filing a claim for Occupational Disease
Within 1 year of date of injury or la...(show more)
Within 1 year of date of injury or last payment. Employee should know relation to employment. Death--within 1 year if death is within 1 year after injury; if not, within 1 year after last medical payment. No claims 240 weeks after injury, except for claims based on asbestos exposure. (show less)
Medical Care Provisions for Occupational Disease claims
Evidenced-based medical treatment
Compensation Provisions for Occupational Diseases
Same as for accidents
Claims settled or resolved
By agreement upon approval of Appeals...(show more)
By agreement upon approval of Appeals Board, which may order hearing. Disputed cases settled by Appeals Board on application (show less)

Administration and Appeals Provisions

Time limit for modifications of award?
No modification after 5 years.
Attorney Fees determined?
Apportionment, if Active
Method for paying Attorney's Fees
Reasonable fee fixed by the WCAB. If ...(show more)
Reasonable fee fixed by the WCAB. If the court finds no reasonable basis for appeal by the employer, insurer or third party administrator, the WCAB may award fees as supplementary award. (show less)
Administrative agency that has purview over appeals provisions
Workers' Compensation Appeals Board
Time requirement to file an appeal
15 Days
Court(s) for Appeals
Workers' Compensation Appeals Boa...(show more)
Workers' Compensation Appeals Board; District Court of Appeals; Supreme Court (show less)
Process and procedure for filing an appeal
Writ of Review
Appeal process by way of a Jury Trial?
No
More State Administration