Workers' Compensation Claim Form (DWC ) & Notice of Potential Eligibility (e)

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An employee uses the Workers' Compensation Claim Form(DWC ) & Notice of Potential Eligibility (e) to formally report a work-related injury or illness to his or her employer and to open a workers' compensation claim file. It must be provided to the injured employee within one working day of knowledge of any injury or illness that requires medical treatment beyond first aid or causes lost time beyond the work shift.
 
You can obtain the Workers' Compensation Claim Form(DWC ) & Notice of Potential Eligibility (e) through State Fund's website: State Contract Forms
 
Guide to Workers' Compensation for New State of California Employees

This pamphlet provides workers' compensation information to new employees, answers frequently asked questions regarding workers' compensation, and has an attached Employee's Predesignation of Personal Physician Form. Employees must cold calling list be given the opportunity to predesignate their treating physician or medical group within days of hire. You can obtain the Guide to Workers' Compensation for New State of California Employees (e) through State Fund's Web site: State Contract Forms.


 
I've Just Been Injured on the Job, What Happens Now? Brochure

This brochure provides answers to the most common questions asked by an injured employee at the onset of the claims process. It is recommended that this brochure be provided along with the Workers' Compensation Claim Form(DWC ) & Notice of Potential Eligibility (e). You can obtain this brochure by visiting the Workers' Compensation Program (WCP) Web site: CalHR's Workers' Compensation Page.
 
Employer's Report of Occupational Injury or Illness (es)

This form must be promptly completed by the employer when an injured employee requires medical treatment beyond first aid or has lost time beyond the date of injury or files a claim for a work-related injury or illness. The completed must be received by State Fund within five calendar days of the employer's knowledge that an injury or illness has occurred. You can obtain the Employer's Report of Occupational Injury or Illness (es) through State Fund's Web site: State Contract Forms
 
The preferred method of completing and submitting the Employer's First Report of Occupational Injury or Illness is electronically via State Fund Online (SFO). For access to SFO, contact your RTWC.
 
STD - Absence and Additional Time Work Report

This form is used to document all time off used by an injured employee. In cases of work-related injuries or illnesses, all time used must be recorded on the STD or equivalent attendance form. This serves as a tracking document when an injured employee's leave time is restored after an injury or illness has been verified by State Fund. You can obtain the STD through the Office of Statewide Publishing (OSP) Web site: DGS STD
 
STD. S - Industrial Disability Leave with Supplementation Benefits Information and Option Selection Form
This form provides an injured employee with information regarding the basic IDL and IDL/S benefits. The injured employee is also provided with a comparison of the amount of IDL they would receive with or without supplementation, and is given the opportunity to select IDL or IDL/S. You can obtain the STD s through the OSP Web site: DGS STD
 
Temporary Disability Verification of State Employee

This form states the dates and hours State Fund has verified as disability periods related to an employee's injury or illness. Without the State Fund the Personnel Office is unable to request and release the IDL benefit.