Virtually all working Californians are "employees" for purposes of workers' compensation. Exemptions are few. People in business for themselves and some unpaid volunteers may not be covered. Maritime workers and federal employees are protected by federal workers' compensation laws.
Any injury or illness is covered if it's caused by the job. The key question is whether the condition "arose out of and occurred in the course of employment".
When does coverage begin?
Employees are covered from the first moment on the job. There's no waiting period, no requirement to work so many days or weeks, no need to earn a minimum amount.
What benefits do injured workers receive?
All reasonable and necessary medical care. Not just doctors' bills, but also medicines, hospital charges, lab tests, X-rays, crutches. The state has set limits on some medical services, for example, the number of visits for chiropractic care and physical therapy are subject to caps set by state law, and non-emergency medical services are subject to pre-authorization, but all costs for reasonable and necessary treatment are paid directly by the claims administrator, without copays or deductibles, so the employee should never see a bill. Partial replacement of lost wages. The most common payment is for "temporary disability" - two-thirds of the employee's average weekly wage up to a maximum set by the state legislature. If the injury results in a permanent disability that the doctor says will leave the employee somewhat limited in his or her ability to work (amputation of a finger for example), additional payments will be made after the employee reaches maximum recovery. Employees with serious injuries that result in permanent disability who are not offered appropriate modified or alternative work, and who cannot return to work for the employer within 60 days after temporary disability ends, will be eligible for a supplemental job displacement benefit. This is a non-transferable voucher for education-related retraining and/or skill enhancement at a state-approved school. Voucher amounts range from $4000 - $10,000 depending on the level of permanent disability.
In fatal injuries, surviving dependents will be paid death benefits and a burial allowance.
How do I report a claim?
When an injury happens, give the employee a DWC-1/Notice of Potential Eligibility claim form. State law requires the employer to furnish the claim form within one day after knowledge of the injury. After the employee returns the completed form, report the claim immediately to the claims administrator by phone or fax because state law requires medical treatment to be authorized with one working day of the employer's receipt of the claim form and the employer is liable for up to $10,000 in medical treatment until the claim is accepted or rejected. Complete the employer section of the claim form and give the employee a signed and dated copy of the completed claim form, send another copy to the insurer and keep one for your files. Most importantly -- even if the employee hasn't returned the claim form -- complete the Employer's Report of Injury (Form 5020), follow the instructions on top of the form, and send it to your insurer.
In August 2015, the state approved regulations revising the Notice of Potential Eligibility (NOPE) and DWC-1 claim form, so as of January 1, 2016, the 1/1/16 version of the claim form should be used. CWCI has preprinted and assembled the 6-part DWC-1/Notice of Potential Eligibility Forms (Rev. 1/16) on NCR paper which makes it much easier to complete and process the form (minimum order 100 forms). Order forms are available by calling 510-251-9470, or click here to order online from our Store. Alternatively, those needing just one claim form may click the Adobe Acrobat file below, which contains the DWC-1/NOPE. The 3-page NOPE, should be provided as a cover page attached to the DWC-1 form. If you are not using the pre-printed 6-part form on NCR paper, you will need to make photocopies, as the state requires the employee be given a copy as a temporary receipt after completing the employee section; then after the employer completes their section, they must keep a signed and dated copy, give one to the claims administrator, and give one to the employee.
If you already have Adobe Acrobat, simply click on the link below to view and print the file.
Click here to download a single copy of the Employee Claim Form for printing.
Click here to download Employer's First Report Form for printing
Self-insured employers should file the electronic version of the Employer’s First Report of Injury with the DWC’s Workers’ Compensation Information System (WCIS).
State law requires insured employers to file the Employer's First Report with their insurer within five days of knowledge of the injury. Self-insured employers must file the Employer's First Report with the state Division of Labor Statistics and Research (DLS&R) within five days of knowledge of the injury, illness or death, and must transmit the doctor's report (Form 5021) to the DLS&R within five days of receipt. State law also requires employers to immediately report any serious injury, illness or death by phone or fax to the nearest Cal-OSHA office. In the event of a serious injury or an employee's death -- even a case that doesn't appear to be work related -- notify the insurer immediately by telephone or fax.
Workers' Compensation Fraud Is A Felony
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 and may be punished by imprisonment in county jail for one year, or in state prison for up to five years, and/or fined up to $150,000 or double the value of the fraud (whichever is greater) and ordered to pay restitution for any medical evaluation or treatment. (IC § 1871.4).