Workers Compensation Procedures for Accident or Injury to Employees. If Immediate Emergency Care is Needed Call 911

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1 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 or ed to

2 State of California Department of Industrial Relations DIVISION OF WORKERS COMPENSATION 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 employer. You may call the Division of Workers Compensation and hear recorded information at (800) 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. Estado de California Departamento de Relaciones Industriales DIVISION DE COMPENSACIÓN AL TRABAJADOR 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) 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. Employee complete this section and see note above 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. Zip. Código Postal. 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. 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. 9. Name of employer. Nombre del empleador. Laguna Beach Unified School District 10. Address. Dirección. 550 Blumont Street, Laguna Beach, CA 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 , Roseville, CA Insurance Policy Number. El número de la póliza de Seguro. Self-Insured Melinda Grace 16. Signature of employer representative. Firma del representante del empleador. 17. Title. Título. HR Technician 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. SIGNING THIS FORM IS NOT AN ADMISSION OF LIABILITY 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. EL FIRMAR ESTA FORMA NO SIGNIFICA ADMISION DE RESPONSABILIDAD Employer copy/copia del Empleador Employee copy/ Copia del Empleado Claims Administrator/Administrador de Reclamos Temporary Receipt/Recibo del Empleado 6/10 Rev.

3 Laguna Beach Unified School District Human Resources Office 550 Blumont Street Laguna Beach, CA x 5211 FAX: 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 Date PRINT NAME

4 Workers Compensation Contact Information for Laguna Beach Unified Claims Administrator Contact Information: Suzie Carmona (909) York Risk Services Group, Inc PO Box Roseville, CA 95661

5

6 Supervisor s Report of Injury Laguna Beach Unified 550 Blumont Street Laguna Beach, CA (949) ext 5211 FOR OFFICE USE ONLY: Received HR or Payroll: Date: BY: 5020 Form Submitted: Date: BY: ***Call Melinda Grace at (949) x 5211 at time of jury*** WORKER S INFORMATION LAST NAME: First Name: DATE OF BIRTH: HOME ADDRESS: City: Zip: PHONE: WORK HOURS: BEGIN: END: Days per Week: Principal/Supervisor s Name: IS THIS A RECURRENCE? LAST DATE WORKED DATE INJURY REPORTED INJURY / ILLNESS DETAILS DATE OF INJURY TIME INJURY REPORTED AM / PM TIME OF INJURY AM / PM EMPLOYEE S DEPARTMENT NAME PART(S) OF BODY INJURED Left NATURE OF INJURY (IE, STRAIN, BRUISE, CUT) DID INCIDENT RESULT IN ILLNESS? WHAT SYMPTOMS EXPERIENCED? 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? BILLING INFORMATION PHYSICIAN S BILLING INFORMATION York Insurance Services Group, Inc If medical services are provided by another physician or PO Box facility a Physician s Report of Injury should be completed Roseville, CA and signed at the health provider s office. Phone: (909) Web Site: If this form is not filled out, the Industrial Commission and insurance carrier will not be officially notified and claim Contact Specialist: Susie Carmona (909) activity can be delayed. Principal or Supervisor s Signature: Date: Time: Title Phone # Complete opposite side and send original copy to HR Page 1

7 WITNESSES # 1 WITNESS: Employee? Directly Involved? CONTACT PHONE: # 2 WITNESS: Employee? Directly Involved? CONTACT PHONE: NAME OF OTHERS INJURED IN THE SAME ACCIDENT: IS PERSONAL PROTECTIVE EQUIPMENT REQUIRED? If yes, explain: WAS IT BEING WORN? If yes, explain: PRIMARY OUTCOME ON THE SCENE: TREATMENT IINFORMATION IF TREATMENT REQUIRED, PLEASE CHECK ONE INJURY 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 DATE OF 1st AID TIME OF 1st AID IF FIRST AID GIVEN: EMPLOYEE NAME NON EMPLOYEE NAME / PH# AM / PM IS VALIDITY OF CLAIM DOUBTED? If Yes, please explain: Original copy to HR Page 2

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