INJURY CHECK LIST: A Detailed document checklist that will ensure you do not miss a step in properly filing a Workers' Compensation Claim.
EMERGENCY SITUATIONS: Procedures designed to assist a Supervisor through emergency situations.
MEDICAL SERVICE ORDER: This form should ALWAYS be sent with the injured worker when they are being sent for treatment to an industrial clinic. This form can also be used by the employee to decline medical treatment. This form is required in triplicate. Please call the Workers' Compensation Division for a supply [951-955-5864]. How do I fill out the Medical Service Order?
FACTS FOR INJURED WORKERS PAMPHLET: This pamphlet has very detailed information about Workers' Compensation rights and benefits.
ACKNOWLEDGEMENT FORM [WC35]: This form is given to an injured employee and it acknowledges their receipt of the Employee Claim Form DWC-1 and of the Facts for Injured Workers' Pamphlet. How do I fill our the Acknowledgement Form?
SUPERVISOR'S REPORT OF EMPLOYEE INJURY: [SAFETY FORM 674]: This is a Safety Form that can be obtained directly from the Human Resources, Safety Web Site. How do I fill out the Supervisor's Report of Employee Injury?
EMPLOYERS FIRST REPORT [FORM 5020]: This is a form filled out by the Supervisor/Manager via the Call Intake Center at 1-888-826-7835. This Form SHOULD NEVER BE FILLED OUT BY HAND. It is a CONFIDENTIAL Form. This means only the Supervisor/Manager (via the Call Intake Center) and the Workers' Compensation Division should have access to this form. How do I fill out the 5020?
EMPLOYEE CLAIM FORM [DWC-1]: This form should be provided to an Employee when the injury is reported, or within 24 hours of when the injury is reported. This form is a multi-copy form. PLEASE make every attempt to utilize the pre-printed form. If you need copies of this form call the Workers' Compensation Division. If you must use the web form, please note the multi-copy requirements and how they must be distributed. How do I fill out the Employee Claim Form?
LOST TIME REPORT [WC-6]: Complete this form and submit the form, along with any original off work orders to the Workers' Compensation Division. How do I fill out the Lost Time Report?