Form 5020 - Employer'S Report Of Occupational Injury Or Illness/form Dwc 1 - Workers' Compensation Claim Form

Download a blank fillable Form 5020 - Employer'S Report Of Occupational Injury Or Illness/form Dwc 1 - Workers' Compensation Claim Form in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Form 5020 - Employer'S Report Of Occupational Injury Or Illness/form Dwc 1 - Workers' Compensation Claim Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

State of California
Please complete in triplicate (type if possible) Mail two copies to:
OSHA CASE NO.
EMPLOYER'S REPORT OF
OCCUPATIONAL INJURY OR ILLNESS
FATALITY
Any person who makes or causes to be made any
California law requires employers to report within five days of knowledge every occupational injury or illness which results in lost time beyond the
knowingly false or fraudulent material statement or
date of the incident OR requires medical treatment beyond first aid. If an employee subsequently dies as a result of a previously reported injury or
material representation for the purpose of obtaining or
illness, the employer must file within five days of knowledge an amended report indicating death. In addition, every serious injury, illness, or death
denying workers compensation benefits or payments is
must be reported immediately by telephone or telegraph to the nearest office of the California Division of Occupational Safety and Health.
guilty of a felony.
1. FIRM NAME
Ia. Policy Number
Please do not use
this column
2. MAILING ADDRESS: (Number, Street, City, Zip)
2a. Phone Number
E
CASE NUMBER
M
P
3. LOCATION if different from Mailing Address (Number, Street, City and Zip)
3a. Location Code
L
OWNERSHIP
O
Y
4. NATURE OF BUSINESS; e.g.. Painting contractor, wholesale grocer, sawmill, hotel, etc.
5. State unemployment insurance acct.no
E
R
6. TYPE OF EMPLOYER:
INDUSTRY
City
School District
Private
State
County
Other Gov't, Specify:
8. TIME INJURY/ILLNESS OCCURRED
10. IF EMPLOYEE DIED, DATE OF DEATH (mm/dd/yy)
7. DATE OF INJURY / ONSET OF ILLNESS
9. TIME EMPLOYEE BEGAN WORK
(mm/dd/yy)
OCCUPATION
AM
PM
AM
PM
1 1. UNABLE TO WORK FOR AT LEAST ONE
12. DATE LAST WORKED (mm/dd/yy)
13. DATE RETURNED TO WORK (mm/dd/yy)
14. IF STILL OFF WORK, CHECK THIS BOX:
FULL DAY AFTER DATE OF INJURY?
Yes
No
15. PAID FULL DAYS WAGES FOR DATE OF
18. DATE EMPLOYEE WAS PROVIDED CLAIM FORM
17. DATE OF EMPLOYER'S KNOWLEDGE /NOTICE OF
SEX
16. SALARY BEING CONTINUED?
NJURY OR LAST
FORM (mm/dd/yy)
INJURY/ILLNESS (mm/dd/yy)
Yes
No
DAY WORKED?
Yes
No
19. SPECIFIC INJURY/ILLNESS AND PART OF BODY AFFECTED, MEDICAL DIAGNOSIS if available, e.g.. Second degree burns on right arm, tendonitis on left elbow, lead poisoning
AGE
I
N
20. LOCATION WHERE EVENT OR EXPOSURE OCCURRED (Number, Street, City, Zip)
DAILY HOURS
20a. COUNTY
21. ON EMPLOYER'S PREMISES?
J
U
Yes
No
R
Y
22. DEPARTMENT WHERE EVENT OR EXPOSURE OCCURRED, e.g.. Shipping department, machine shop.
23. Other Workers injured or ill in this event?
DAYS PER WEEK
Yes
No
24. EQUIPMENT, MATERIALS AND CHEMICALS THE EMPLOYEE WAS USING WHEN EVENT OR EXPOSURE OCCURRED, e.g.. Acetylene, welding torch, farm tractor, scaffold
O
R
WEEKLY HOURS
25. SPECIFIC ACTIVITY THE EMPLOYEE WAS PERFORMING WHEN EVENT OR EXPOSURE OCCURRED, e.g.. Welding seams of metal forms, loading boxes onto truck.
I
WEEKLY WAGE
L
L
26. HOW INJURY/ILLNESS OCCURRED. DESCRIBE SEQUENCE OF EVENTS. SPECIFY OBJECT OR EXPOSURE WHICH DIRECTLY PRODUCED THE INJURYIILLNESS, e.g.. Worker stepped back to inspect work
N
and slipped on scrap material. As he fell, he brushed against fresh weld, and burned right hand. USE SEPARATE SHEET IF NECESSARY
E
COUNTY
S
S
27. Name and address of physician (number, street, city, zip)
27a. Phone Number
NATURE OF INJURY
28a. Phone Number
No
Yes
If yes then, name and address of hospital (number, street, city, zip)
28. Hospitalized as an inpatient overnight?
PART OF BODY
29. Employee treated in emergency room?
Yes
No
ATTENTION 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
SOURCE
while the information is being used for occupational safety and health purposes. See CCR Title 8 14300.29 (b)(6)-(10) & 14300.35(b)(2)(E)2.
Note: Shaded boxes indicate confidential employee information as listed in CCR Title 8 14300.35(b)(2)(E)2*.
30. EMPLOYEE NAME
32. DATE OF BIRTH (mm/dd/yy)
31. SOCIAL SECURITY NUMBER
EVENT
33. HOME ADDRESS (Number, Street, City,Zip)
33a. PHONE NUMBER
E
SECONDARY SOURCE
M
P
35. OCCUPATION (Regular job title, NO initials, abbreviations or numbers)
34. SEX
36. DATE OF HIRE (mm/dd/yy)
L
O
Male
Female
Y
37b. UNDER WHAT CLASS CODE OF YOUR
37a. EMPLOYMENT STATUS
37. EMPLOYEE USUALLY WORKS
E
POLICY WHERE WAGES ASSIGNED
part-time
regular, full-time
E
hours per day,
days per week,
total weekly hours
temporary
seasonal
EXTENT OF INJURY
39. OTHER PAYMENTS NOT REPORTED AS WAGESISALARY (e.g. tips, meals, overtime, bonuses, etc.)?
38. GROSS WAGES/SALARY
per
$
Yes
No
Date (mm/dd/yy)
Signature & Title
Completed By (type or print)
• Confidential information may be disclosed only to the employee, former employee, or their personal representative (CCR Title 8 14300.35), to others for the purpose of processing a workers' compensation or other insurance
.
claim; and under certain circumstances to a public health or law enforcement agency or to a consultant hired by the employer (CCR Title 8 14300.30). CCR Title 8 14300.40 requires provision upon request to certain state and
federal workplace safety agencies.
FORM 5020 (Rev7) June 2002
FILING OF THIS FORM IS NOT AN ADMISSION OF LIABILITY

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Business
Go
Page of 4