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Workers’ Compensation Procedures for Accident or Injury to
Employees
If Immediate Emergency Care is Needed Call 911
When an employee reports or suffers an on-the-job injury, the following
procedure and forms are required to be provided and carried out immediately
upon notice:
1) Provide the employee with the following forms:
a. WC DWC-1 Form
b. Acknowledgement of Receipt Form
c. Authorization for Medical Services
d. WC Claims Administrator Contact Information
2) Have the employee complete, sign and return to you the following:
a. Acknowledgement of Receipt Form
b. WC DWC-1 Form (if employee states they will be seeking medical care)
3) Have your Principal or Site Supervisor fill out the following form:
a. Supervisor’s Report of Injury
4) Return the following to Human Resources as soon as possible:
a. Completed Acknowledgement of Receipt Form
b. Completed WC DWC-1 Form (if employee states they will be seeking medical care)
c. Completed Supervisor’s Report of Injury
If the employee chooses not to seek medical attention, please provide all the
above information, however the employee retains the DWC-1 Form but must sign
the Acknowledgment of Receipt Form. Completed forms may be faxed to 949497-7700 or emailed to [email protected]
State of California
Department of Industrial Relations
DIVISION OF WORKERS’ COMPENSATION
Estado de California
Departamento de Relaciones Industriales
DIVISION DE COMPENSACIÓN AL TRABAJADOR
WORKERS’ COMPENSATION CLAIM FORM (DWC 1)
Employee: Complete the “Employee” section and give the form to
your employer. Keep a copy and mark it “Employee’s Temporary
Receipt” until you receive the signed and dated copy from your em ployer. You may call the Division of Workers’ Compensation and
hear recorded information at (800) 736-7401. An explanation of workers' compensation benefits is included as the cover sheet of this form.
You should also have received a pamphlet from your employer describing workers’ compensation benefits and the procedures to obtain
them.
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.
Employee—complete this section and see note above
PETITION DEL EMPLEADO PARA DE COMPENSACIÓN DEL
TRABAJADOR (DWC 1)
Empleado: Complete la sección “Empleado” y entregue la forma a su
empleador. Quédese con la copia designada “Recibo Temporal del
Empleado” hasta que Ud. reciba la copia firmada y fechada de su empleador.
Ud. puede llamar a la Division de Compensación al Trabajador al (800) 7367401 para oir información gravada. En la hoja cubierta de esta
forma esta la explicatión de los beneficios de compensación al trabajador.
Ud. también debería haber recibido de su empleador un folleto describiendo los
benficios de compensación al trabajador lesionado y los procedimientos para
obtenerlos.
Toda aquella persona que a propósito haga o cause que se produzca
cualquier declaración o representación material falsa o fraudulenta con el
fin de obtener o negar beneficios o pagos de compensación a trabajadores
lesionados es culpable de un crimen mayor “felonia”.
Empleado—complete esta sección y note la notación arriba.
1.
Name. Nombre. _____________________________________________Today’s Date. Fecha de Hoy.
2.
Home Address. Dirección Residencial. _______________________________________________________________________________________
3.
City. Ciudad. _______________________________________ State. Estado. __________________
4.
Date of Injury. Fecha de la lesión (accidente). ________________________ Time of Injury. Hora en que ocurrió. _________a.m. ________p.m.
5.
Address and description of where injury happened. Dirección/lugar dónde occurió el accidente. _________________________________________
___________________________________
Zip. Código Postal. ___________________
_______________________________________________________________________________________________________________________
6.
Describe injury and part of body affected. Describa la lesión y parte del cuerpo afectada. _______________________________________________
_______________________________________________________________________________________________________________________
7.
Social Security Number. Número de Seguro Social del Empleado.
8.
Signature of employee. Firma del empleado.
_______________________________________________________________
_________________________________________________________________________________
Employer—complete this section and see note below. Empleador—complete esta sección y note la notación abajo.
Laguna Beach Unified School District
Name of employer. Nombre del empleador. ___________________________________________________________________________________
550
Blumont
Street,
Laguna Beach, CA 92651
10. Address. Dirección. _____________________________________________________________________________________________________
9.
11. Date employer first knew of injury. Fecha en que el empleador supo por primera vez de la lesión o accidente. _____________________________
12. Date claim form was provided to employee. Fecha en que se le entregó al empleado la petición. _________________________________________
13. Date employer received claim form. Fecha en que el empleado devolvió la petición al empleador. _______________________________________
14. Name and address of insurance carrier or adjusting agency. Nombre y dirección de la compañía de seguros o agencia adminstradora de seguros.
York Risk Services Group, Inc. P.O. Box 619079, Roseville, CA 95661
_______________________________________________________________________________________________________________________
Self-Insured
15. Insurance Policy Number. El número de la póliza de Seguro. _____________________________________________________________________
Melinda Grace
16. Signature of employer representative. Firma del representante del empleador. _______________________________________________________
HR Technician
866-221-2402
17. Title. Título. _____________________________________
18. Telephone. Teléfono. _______________________________________________
Employer: You are required to date this form and provide copies to
your insurer or claims administrator and to the employee, dependent
or representative who filed the claim within one working day of
receipt of the form from the employee.
Empleador: Se requiere que Ud. feche esta forma y que provéa copias a su compañía de seguros, administrador de reclamos, o dependiente/representante de reclamos y al empleado que hayan presentado esta petición dentro del plazo de un día
hábil desde el momento de haber sido recibida la forma del empleado.
SIGNING THIS FORM IS NOT AN ADMISSION OF LIABILITY
EL FIRMAR ESTA FORMA NO SIGNIFICA ADMISION DE RESPONSABILIDAD
❑ Employer copy/Copia del Empleador
6/10 Rev.
❑ Employee copy/ Copia del Empleado
❑ Claims Administrator/Administrador de Reclamos
❑ Temporary Receipt/Recibo del Empleado
Laguna Beach Unified School District
Human Resources Office
550 Blumont Street
Laguna Beach, CA 92651
949-497-7700 x 5211
FAX: 949-497-7710
ACKNOWLEDGEMENT OF RECEIPT
Due to a possible workers’ compensation injury I have been offered the Laguna Beach Unified
Workers’ Compensation information packet and the State of California Department of lndustrial
Relations Division of Workers' Compensation (DWC-1) claim form. I understand and acknowledge
the following:
I am in receipt of the DWC-l claim form and information packet. I understand that I
must fill out and return the enclosed materials as soon as possible to my Principal,
Supervisor, or HR office.
I am in receipt of the information and claim forms packet including the DWC-1
and voluntarily decline medical treatment at this time.
I voluntarily decline the information and claim forms packet which includes the DWC-1
form at this time.
SIGNATURE OF EMPLOYEE
PRINT NAME
Date
Workers Compensation Contact
Information for Laguna Beach Unified
Claims Administrator Contact Information:
Suzie Carmona
(909) 942-4895
York Risk Services Group, Inc
PO Box 619079
Roseville, CA 95661
FOR OFFICE USE ONLY:
Laguna Beach Unified
550 Blumont Street
Laguna Beach, CA 92651
(949) 497-7700 ext 5211
Supervisor’s
Report of Injury
Received HR or Payroll:
Date:
BY:
5020 Form Submitted:
Date:
BY:
***Call Melinda Grace at (949) 497-7700 x 5211 at time of jury***
WORKER’S INFORMATION
LAST NAME:
First Name:
DATE OF BIRTH:
HOME ADDRESS:
City:
Zip:
WORK HOURS:
BEGIN:
END:
PHONE:
Days per Week: ____________________
Principal/Supervisor’s Name:
INJURY / ILLNESS DETAILS
DATE OF INJURY
TIME OF INJURY
TIME INJURY REPORTED
AM / PM
EMPLOYEE’S DEPARTMENT
NAME
IS THIS A RECURRENCE?
LAST DATE WORKED
DATE INJURY
REPORTED
AM / PM
PART(S) OF BODY INJURED
NATURE OF INJURY – (IE,
STRAIN, BRUISE, CUT)
DID INCIDENT RESULT IN ILLNESS? WHAT SYMPTOMS
EXPERIENCED?
Left ___
Right ___
INJURY / ILLNESS DETAILS: WHAT HAPPENED?
WHERE WAS INJURY TREATED?
NO TREATMENT
Sand Canyon Urgent Care Center - Irvine
OTHER - NAME OF PHYSICIAN / HOSPITAL / FACILITY NAME
NAME OF FACILITY:
PHYSICIAN NAME:
ADDRESS:
CITY, STATE, ZIP:
PHONE NUMBER:
WAS EMPLOYEE HOSPITALIZED OVERNIGHT? YES / NO
BILLING INFORMATION
PHYSICIAN’S BILLING INFORMATION
York Insurance Services Group, Inc
If medical services are provided by another physician or
facility a Physician’s Report of Injury should be completed
PO Box 619079
and signed at the health provider’s office.
Roseville, CA 95661
Phone: (909) 942-4895
If this form is not filled out, the Industrial Commission and
Web Site: www.yorkisg.com
insurance carrier will not be officially notified and claim
Contact Specialist: Susie Carmona (909) 942-4895
activity can be delayed.
Principal or Supervisor’s
Signature:________________________________________________________Date:________________Time:___________
Title______________________________________________________________Phone #____________________________
Complete opposite side and send original copy to HR
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WITNESSES
Employee?
Directly Involved?
# 1 WITNESS:
# 2 WITNESS:
YES / NO
YES / NO
Employee?
Directly Involved?
YES / NO
YES / NO
CONTACT
PHONE:
CONTACT
PHONE:
NAME OF OTHERS INJURED IN THE SAME ACCIDENT:
IS PERSONAL PROTECTIVE EQUIPMENT REQUIRED?
WAS IT BEING WORN?
YES / NO
If yes, explain:
YES / NO
If yes, explain:
ON THE SCENE: TREATMENT IINFORMATION
PRIMARY OUTCOME
INJURY
IF TREATMENT REQUIRED, PLEASE CHECK ONE
ILLNESS
DEATH
MEDICAL
FIRST AID
NONE
AT THE SCENE OF INJURY, DID ONE OF THE FOLLOWING OCCUR?
PATIENT TAKEN TO
HOSPITAL
PATIENT FELL
UNCONSCIOUS
FATAL INJURIES
SUSTAINED
RESUSCITATION
REQUIRED
AMBULANCE
REQUIRED
IF FIRST AID GIVEN:
DATE OF 1st AID
TIME OF 1st AID
EMPLOYEE NAME
NON EMPLOYEE NAME / PH#
AM / PM
IS VALIDITY OF CLAIM DOUBTED?
YES / NO
If Yes, please explain:
Original copy to HR
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