California Required Postings and Forms
Download California Claims Kit
Please print and post the following notices, both in English and Spanish, in a conspicuous location frequented by employees such as the break room, lunch room or time clock. If you have multiple business locations, be sure to post the notices at each location.
- DWC-7 Notice to Employees-Injuries Caused by Work (English and Spanish). This form provides your employees with information regarding workers’ compensation benefits and the Medical Provider Network (MPN) in California. In addition to this being posted in a conspicuous place, it must be given to all employees at time of hire. Please complete the blank fields.
- Covered Employee Notification of Rights Material (English and Spanish). Post this notice adjacent to the workers’ compensation Posting Notice DWC-7.
- Division of Workers’ Compensation Fact Sheet (English, Spanish, Chinese, Korean, Tagalog and Vietnamese). This fact sheet provides injured workers with answers to frequently asked questions about issues affecting their benefits.
Please print and review the following forms with your current staff and new employees (at the time of hire):
- DWC-7 Notice to Employees-Injuries Caused by Work (English and Spanish). This form provides your employees with information regarding workers’ compensation benefits and the Medical Provider Network (MPN) in California. In addition to this being posted in a conspicuous place, it must be given to all employees at time of hire. Please complete the blank fields.
- Covered Employee Notification of Rights Material (English and Spanish). This information explains important information about your employee’s medical care in the event of a work-related injury or occupational disease. This notification should be provided to all new employees by the end of their first pay period. This notice shall also be provided upon request by an existing, covered employee when there is a change in MPN’s. Please post this notice next to your DWC-7 poster and provide a copy to employees after they have sustained a work-related injury or occupational disease.
- Time of Hire Pamphlet (English and Spanish). This pamphlet provides your employees with information about workers’ compensation in general and the benefits afforded to injured workers in California. This PDF file allows you to add information that is specific to your company such as the nearest Division of Workers’ Compensation Information and Assistance (I&A) Unit and your company’s predesignated personal physician. This notice must be provided to all new employees at time of hire or no later than the employee’s receipt of his/her paycheck.
- MPN Implementation Notice (English and Spanish). This notice should be provided to all employees prior to the implementation of an MPN and at time of hire for new employees. This notice should be placed on your company letterhead. You should maintain documentation that you provided this information to your employees. The language on the MPN Implementation Notice should not be modified or altered, however, you may add additional information if deemed appropriate–such as whom within the company employees may contact if they have questions about the notice.
The following forms need to be completed and submitted to EMPLOYERS when a work-related injury occurs:
- 5020 Employers Report of Occupational Injury or Occupational Disease. As soon as you have been notified of a work-related injury or occupational disease, please fill out this form and submit it to EMPLOYERS. This form must be completed within five days from notice of an accident/occupational disease that results in lost time beyond the date of incident or requires treatment beyond first aid. Fatalities must be reported within 24 hours.
- DWC-1 Workers Compensation Claim Form. This is the form you will complete and send to EMPLOYERS to initiate the claim process for your employee. This form must be completed and provided to EMPLOYERS within one working day from you becoming aware of a work-related injury or occupational disease. Please provide a copy to your employee and keep a copy for your records.
- Covered Employee Notification of Rights Material (English and Spanish). This information explains important information about your employee’s medical care in the event of a work-related injury or occupational disease. This notice must be provided to employees after they have sustained a work-related injury or occupational disease. This notice shall also be provided upon request by an existing, covered employee when there is a change in MPN’s.
- Wage Statement. This form enables us to calculate the correct compensation that may be owed to an injured employee. Please complete the form and submit it to EMPLOYERS within five days after your knowledge of any accident that has caused your employee to be disabled for more than seven scheduled work calendar days.
- First Fill Form. This form provides your employees with basic information about our Pharmacy Benefit Program, including such things as the phone number to call to locate a First Fill participating pharmacy. When your employee becomes injured, please print and complete this form and provide it to your injured employee. Your employee will need to provide this completed form along with the prescription for his/her work-related injury or occupational disease to the pharmacist. Using this form will help enable quick authorization for your employee’s initial medication and ensure that the initial prescription is provided at no cost to the injured employee.
- Accident Investigation Report. This basic accident form should be completed by the employee’s supervisor/manager as soon as possible after the accident. Please send the report to the following EMPLOYERS address as soon as it has been completed by the supervisor/manager: EMPLOYERS Claim Department, P.O. Box 14791, Lexington, KY 40512-4791. You should also keep a copy on file for your records.
More California Workers’ Comp Resources
- Off-Site Transitional Duty Program – Helping Your Injured Employees Get Back to Work. A successful transition back to work relies on the collaborative efforts of the manager/supervisor, the injured employee and their adjuster. As a manager/supervisor, learn what you can do to help facilitate a successful return to work.