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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. Exceptions to the California workers’ compensation law applicable to corporate officers, members of Boards of Directors, partnerships, and LLCs are included in Labor Code Sections 3351 and 3352 (http://codes.findlaw.com/ca/labor-code/).
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?
With the exception of certain psychiatric injuries and some residential employees, employees are covered from the first moment on the job. There's no waiting period, no requirement to work so many days or weeks, and 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, and the like. The state has set limits on some medical services; for example, the number of visits for chiropractic care and physical therapy for injuries on or after 1/1/04 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 will leave the employee limited in his or her ability to work, additional payments may be made after the employee reaches maximum recovery.
Return-to-work benefits. Employees with serious injuries that result in permanent disability who are not offered appropriate regular, modified or alternative work within 60 days after the claims administrator’s receipt of the Physician’s Return to Work & Voucher Report, will be eligible for a supplemental job displacement benefit (SJDB). This is a non-transferable voucher for education-related retraining and/or skill enhancement at a state-approved school, or other resources (tools, licenses, computer equipment) to help the injured worker find a new job. For injuries on and after 1/1/13, the voucher can be redeemed for up to $6,000 worth of expenses, though there are limits on the amounts available for certain expense items, including $500 for miscellaneous expenses and $1,000 for computer equipment. Receipt of a voucher also entitles the injured worker to apply to the California Department of Industrial Relations (DIR) for an additional $5,000 from DIR’s Return-to-Work Supplemental Program (RTWSP). Details are found here: http://www.dir.ca.gov/RTWSP/RTWSP.html
Death benefits. In fatal injuries, individuals who are financially dependent on the worker are eligible for death benefits. The amount is based on the date of injury and the number of dependents. Death benefit payments are made at the same rate as temporary disability payments, but no payments will be less than $224/week. In addition, workers’ compensation death benefits include a a burial allowance of up to $10,000.
How do I report a claim?
If a work injury occurs and emergency care is needed, immediately call 911 or take the injured worker to the nearest emergency room. In all cases, give the employee or their representative a DWC-1/Notice of Potential Eligibility claim form as state law requires the employer to furnish the claim form within one day after knowledge of the injury. Prompt reporting is key, as state law also requires medical treatment to be authorized within 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, so after the employee returns the completed form, report the claim immediately to the claims administrator by phone or fax. 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.
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 to the injured worker or their representative 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. After you complete the employer’s section, you 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).
For insured employers, state law requires the filing of 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 all 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 -- the employer should notify the insurer immediately by telephone or fax.
Q. What is the definition of a “first aid” injury and what are the reporting requirements for these types of injuries?
A. Labor Code section 5401(a) defines first aid as “any one-time treatment and any follow up visit for the purpose of observation of minor scratches, cuts, burns, splinters, or other minor industrial injury, which do not ordinarily require medical care. This one-time treatment and follow up visit for the purpose of observation is considered first aid even though provided by a physician or registered professional personnel.”
Employers do not need to file a DWC-1 Claim Form or an Employers' Report of Occupational Injury or Illness (Form 5020) for injuries that result in first aid treatment only, and such injuries do not need to be included on OSHA Injury and Illness Recordkeeping Forms. However, amendments to the Workers’ Compensation Insurance Rating Bureau’s Unit Statistical Reporting Plan that took effect 1/1/17 require insurers to report the cost of all claims for which any medical care is provided and medical costs are incurred, including those involving first aid treatment (even if the insurer did not make the payment), so employers should report the cost of any first aid treatment to their workers’ compensation insurer.
Note: the employer must notify the Administrative Director (AD), via “Notice of Employee Death” (DIA Form 510), of the death of every employee regardless of cause of death, except where the employer has actual knowledge or notice that the deceased employee has left a surviving minor child. The Notice of Employee Death is to be filed within 60 days of the employer’s notice or knowledge of the employee death; the employer may forward the Notice of Employee Death to the workers’ compensation insurer for subsequent submission to the AD. The DIA Form 510 can be found here: https://www.dir.ca.gov/dwc/diaform510.pdf
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).