Acclamation Insurance Management Services

1. FIRM NAME

o

I !::ilaleOI.UlIlOm,a

EMPLOYER'S REPORT OF

OCCUPATIONALINJURYOR ILLNESS

Pleasecomplete

in

triplicate(type

if possible)mail

two copias

to:

I

CENTRAL

SAN JOAQUIN

VAL~EY

RISK

MANAGEMENT

AUTHORITY

Administrated

by:

ACCLAMATlO~

INSURANCE

MANAGEMENT

SERVICES

559-227-9891 •

P.O.

Box

28100·

Fresno,

CA 93729

FATALITY

OSHA CASE

NO.

Any person who makes or causes to be made any

knowingly

false or fraudulent material statement or

material representation for the purpose of obtaining or

denying workers compensation

benefits or payments is

guilty of a felony.

California law requires employers to

report

within five days of knowiedge every occupational

injury

or illness which results in lost time beyond the

date of the

incident

OR requires

medicallrealmen~beyond first

aid.

If an

employee subsequently dies as a

result

of a previously reported injury or

illness,

the

employer

must

file within five days of ~Owledge an amended

report

indicating

death.

In

addition,

every serious

injury,

illness,

or

death

must be reported immediately by telephone or telegraph to the nearest office

of

the California Division of Occupational Safety and Health.

I

I

Ia, Policy Number

2a.

Phone Number

Please do not use

this column

; 2. MAILING

ADDRESS:

(Number,

Stree~ City, Zip)

I

~~3 •.~LOnC~A"Tr.IOnN~W~d~~~~~n~trro~m~M~ai"'lin~g~A"d"d~~~~~(Nu.u~m~b~e~~.ST.tr~u~~'C",ity~a=nd7TZi=p')------~----------~I----------------------~h3a~L~O~~~ti~·o=nrC~o

•• de~--------------1~--

__ ~~~~~

o

OWNERSHIP

:h4,.NAu.r,TnU~R~ErO~F~BmU~SlmN~E~SSo.;~.~.g~"DPa~in~t~in=g~co~n~tr~aa~M~,wn="-o~le~s~~~e~gr~o~ce~r,~s~aw~m=i"'I/,'h~o'-te'I,~et~c'--------------'I----------------------~~5'.~SU~t.~u~n~em=p~l~o~~e~nTti~n~su~r~an~~~a~cc~L~

Oily

I

DSthcolDiSlricl

CASE NUMBER

6..TYPE OF

EMPLOYER:

0

D

D

Privale

Slate

oumy

OherGOyt,

Spoolfy:

INDUSTRY

7.

DATE OFINJURY IONSET OFILLNESS 8. TIME INJURynLLNESS OCCURRED

(mmlddlyy)

PM

PM

SEX

AM

9.TIMEEMPLOYEE

BEGAN

WORK

I

AM

10.IFEMPLOYEE

DIED,

DATE OFDEATH (mmlddlyy)I---,====,.--l

OCCUPATION

11.UNABlfTOWORK FORATLEAST ONE12. DATE LASTWORKED(mmlddlyy)

3 DATEReTuRNEDTO WORK(mmlddlyy)

14.IF STilL

OFFWORK,CHECKTHISBOX:

FULL DAY AFTEI}I!AI;OFINJURY?

.

I

D

Des

UNO

15.

P AID FULL DAYS WAGES F OR DATE OF 16.SALARYBEINGCONTINUED?

17.DATEOFEMPLOYER'S KNOWlEDGE/NOTICE OF 11.DATE EMPLOYEE WASPROVIDED ClAIMFORM

NJURYORlAST

O

0

Dyes

DNa

INJURynllNESS(mmiddlyy)

FORM(mmlddlyy)

DAY WORKED?

Yes

No

I

I 19.SPECIFIC INJURYlilLNESS ANDPARTOFBODYAFFECTED, M EDICAL DIAGNOSIS ff

available,e.g..Secondde91

bums on right

arm,

lendonilis on left elbow,leadpoisoning

~"'~__ m_"~,"~"_m.".~._," .• "

"'

' ' '

T

".""

O ~::"'·"[j:'

y 22.DEPARTMENT W HERE EVENT OREXPOSURE OCCURRED, e.g•. ShippIngdepartment,machineshop.

I

p3.

OtherWorl<ers injuredor ill in thi~?

IDes

LJNo

AGE

DAILY HOURS

DAYS PER WEEK

o

24.

EQUIPMENT, MATERIALS AND CHEMICALS THE EMPLOYEE WAS USING WHEN EVENT OR EXPOSURE

OCCURRED,

o.g•.

Acetylene,

welding.

torch, farm tractor, scaffold

R

I

WEEKLY HOURS

5. SPECIFIC ACTIVITY THE EMPLOYEE WAS PERFORMING WHEN EVENT OR EXPOSURE

OCCURREDI

e.g.. Welding seams of metal forms, loading boxes onto truck.

I

L

L

1:

2 "'6."'H=OW=IN"J'"'UR"'y"'n"ll"'N"'ES"'S"'0""C"'C::":'UR:::RE=O-:.

O""E=SC:::R/"'a"'E"'S"'E=a"'UE"'N"'C"'e-=O':'F:::EVE=NTS=-.""SP"'E"'C"'IFY=O=BJ"'E=Cr::'O:::R;:"EXP==O:::SU"'R"'E"'WH=IC=O"'IR"'E=CTL=Y-=P"'RO:::O:;:'U"'C""EO;:"TH=E"IN"'J"'UR:::Y:;;;II"lL"'N"'E

:-e.g:-

..

" W"'o"'rI<":'er:-:st::':e":'pped=L:ba=c::'k

l::o-::ins=pe=ct::wc=rI<-i

N and slipped on scrap material. As he

fell.

he brushed against fresh weld, and burned right hand. USE SEPARATE SHEET IF ECESSARY

E

5

S

WEEKLY WAGE

COUNTY

NATURE OF INJURY

PART OF BODY

A.TTENTION This form contains information

relating to employee health and must be used in a manner that protects the confidentiality

of employees to the extent possible

white the information

is being used for occupational

safety and health

purposes.

See CCR Title 8114300.29 (b)(6)-(10)

&

14300.35(b)(2)(E)2.

Note:

Shaded

boxes

Indicate

confidential

employee

InformatIon

as listed

In CCR TrUe 8

14300.35(b)(2)(E)T.

SOURCE

32.DATE-OF,!IIRTll (min/dl\fy)'l

..

...•.

31. SOcr,\LSECURlTY

NU;>ffiER

,

.

EVENT

E

3J;

HOMEA!iDREss

lNulnb.r,

Street,

Ci1:)',Zip)

.

.

JI

~~~~~~,~,.,~~---~:~~~~.~.~

...

~~~~~~~~~.~.~~~

..

~~.~--------~--~--~~~--~--~~~~'~~~.'~.,~.~

L

.3>t:Sl'x,

...' •......",

..

'....

,...

.•

'.135. OCCUPATION(Regular job title, NO initials, abbreviations or nurnoers)

ss,

DATE01' IDREImmjd:!'YJ)

E

~3g~;;~EJ5L::~sl

.

37a.EMPloYMENTSTATUS

7b.UNDERWHArCLASSCODEOFYOUR

D~gular.

full.time

0

part-time

POUCYWHEREWAGESASSIGNED

E

hours per

day,

days per

wuk,

total weokly hours

I

Dtemporary

0

seasonal

I

33a.

PHONE,NUMBER

SECONDARYSOURCE

Completed By (type or print)

EXTENT OF INJURY

3B.

GROSSWAGES/SALARY

$

per

39.OTHE~PAYMENTS N Or REPORTED ASWAGESISALARY

(e.g.tips,

meals,overtime,bonuses,etc.)?

Dies

DNO

Date (mmldd/yy)

Signature

&

Title

• Confidential information

may be disclosed only to the amp! yee, former

employee.

or their personal

representative

{CCR Title 8

14300.35},

to oUters for the purpose of processing a workers' compensation or other insurance

claim;

and under certain circumstances to a public he~th or law enforcement agency or to a consultant hired by the

employer

(CCR Title 8

14300.30).

CCRTitle 8 14300.40requires pnovision upon request to certain slate and

(

Lf~ed~e~r~a~lw~o~~~pl~a~ce~s~~~ety~a~g~en~c~ie~s~.

-:-

.

~

FORM 5020 (Rev7) June 2002

I

FILING OF THIS FORM IS NOT AN ADMISSION OF LIABILITY

DISTRIBUTION:

WHITE=WORKERS'

COMPENSATION·

CANARY=WORK~RS'

COMPENSATION·

PINK=PERSONNEL

DEPT