The 5020 California form is the Employer's Report of Occupational Injury or Illness, required by state law for reporting workplace injuries or illnesses. Employers must complete this form within five days of learning about any incident that leads to lost time or requires medical treatment beyond first aid. Timely submission is crucial for compliance and to ensure proper handling of workers' compensation claims.
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The 5020 California form is a critical document for employers in the state, designed to report occupational injuries or illnesses. Timeliness is essential; employers must complete this form within five days of becoming aware of any incident that leads to lost time or requires medical treatment beyond first aid. The form requires detailed information, including the nature of the business, specifics about the injury or illness, and employee details. Employers must also provide information about the circumstances surrounding the incident, such as the location, the equipment involved, and the activities being performed at the time. If an employee dies as a result of the injury, an amended report must be filed within five days. It is important to note that any false statements made on this form can lead to serious legal consequences. Employers must submit two copies to SeaBright Insurance Company and retain a copy for their records. By adhering to these guidelines, employers ensure compliance with California law and contribute to workplace safety and accountability.
State of California
EMPLOYER'S REPORT OF OCCUPATIONAL INJURY OR ILLNESS
Please complete in triplicate (type if possible) Mail two copies to:
SeaBright Insurance Company
PO Box 11027
Orange, CA 92856-8127
Fax: (714) 918-5972
Email: ca-claims@sbic.com
OSHA CASE NO.
FATALITY
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.
California law requires employers to report within five days of knowledge every occupational injury or illness which results in lost time beyond the date of the incident OR requires medical treatment beyond first aid. If an employee subsequently dies as a result of a previously reported injury or illness, the employer must file within five days of knowledge an amended report indicating death. In addition, every serious injury, illness, or death must be reported immediately by telephone or telegraph to the nearest office of the California Division of Occupational Safety and Health.
1. FIRM NAME
1a. Policy Number
Please do not use
E
this column
2. MAILING ADDRESS: (Number, Street, City, Zip)
2a. Phone Number
M
P
CASE NUMBER
L
3. LOCATION if different from Mailing Address (Number, Street, City and Zip)
3a.Location Code
O
OWNERSHIP
Y
4. NATURE OF BUSINESS; e.g.. Painting contractor, wholesale grocer, sawmill, hotel, etc.
5. State unemployment insurance
acct. no.
R
6. TYPE OF EMPLOYER:
Private
State
County
City
School District
Other Gov’t, specify
INDUSTRY
7. DATE OF INJURY / ONSET OF
8. TIME INJURY/ILLNESS OCCURRED
9. TIME EMPLOYEE BEGAN WORK
10. IF EMPLOYEE DIED, DATE OF DEATH
ILLNESS (mm/dd/yy)
(mm/dd/yy)
AM
PM
OCCUPATION
11. UNABLE TO WORK FOR AT
12. DATE LAST WORKED (mm/dd/yy)
13. DATE RETURNED TO WORK (mm/dd/yy)
14. IF STILL OFF WORK, CHECK THIS
LEAST ONE FULL DAY AFTER DATE
BOX:
OF INJURY?
Yes
No
I
15. PAID FULL DAY'S WAGES FOR
16. SALARY BEING CONTINUED?
17. DATE OF EMPLOYER'S KNOWLEDGE /NOTICE OF
18. DATE EMPLOYEE WAS PROVIDED
SEX
DATE OF INJURY OR LAST DAY
INJURY/ILLNESS (mm/dd/yy)
CLAIM FORM (mm/dd/yy)
N
WORKED?
J
19. SPECIFIC INJURY/ILLNESS AND PART OF BODY AFFECTED, MEDICAL DIAGNOSIS if available, e.g.. Second degree burns on right arm, tendonitis on left elbow, lead poisoning
AGE
U
20. LOCATION WHERE EVENT OR EXPOSURE OCCURRED (Number, Street, City, Zip)
20a. COUNTY
21. ON EMPLOYER'S PREMISES?
DAILY HOURS
22. DEPARTMENT WHERE EVENT OR EXPOSURE OCCURRED, e.g.. Shipping department, machine shop.
23. Other Workers Injured/Ill in this event?
DAYS PER WEEK
24. EQUIPMENT, MATERIALS AND CHEMICALS THE EMPLOYEE WAS USING WHEN EVENT OR EXPOSURE OCCURRED, e.g.. Acetylene, welding torch, farm tractor, scaffold:
WEEKLY HOURS
25. SPECIFIC ACTIVITY THE EMPLOYEE WAS PERFORMING WHEN EVENT OR EXPOSURE OCCURRED, e.g.. Welding seams of metal forms, loading boxes onto truck.
WEEKLY WAGE
L26. HOW INJURY/ILLNESS OCCURRED. DESCRIBE SEQUENCE OF EVENTS. SPECIFY OBJECT OR EXPOSURE WHICH DIRECTLY PRODUCED THE INJURY/ILLNESS, e.g.. Worker stepped back to L inspect work and slipped on scrap material. As he fell, he brushed against fresh weld, and burned right hand. USE SEPARATE SHEET IF NECESSARY.
COUNTY
S
S 27. NAME AND ADDRESS OF PHYSICIAN (Number, Street, City, Zip)
27a. Phone Number
NATURE OF
INJURY
28. HOSPITALIZED AS AN INPATIENT OVERNIGHT?
28a. Phone Number
If yes then, NAME AND ADDRESS OF HOSPITAL (Number, Street, City, Zip).
PART OF BODY
29. Employee treated in Emergency Room?
ATTENTION: This form contains information relating to employee health and must be used in a manner that protects the confidentiality of
employees to the extent possible while the information is being used for occupational safety and health purposes.
SOURCE
See CCR Title 8 14300.29 (b)(6)-(10) & 14300.35(b)(2)(E)2.
Note: Shaded boxes indicate confidential employee information as listed in CCR Title 8 14300.35(b)(2)(E)2.*
30. EMPLOYEE NAME
31. SOCIAL SECURITY NUMBER
32. DATE OF BIRTH (mm/dd/yy)
EVENT
33. HOME ADDRESS (Number, Street, City, Zip)
33a. PHONE NUMBER
SECONDARY
34. SEX:
Female
35. OCCUPATION ( Regular job title, NO initials, abbreviations or numbers)
36. DATE OF HIRE (mm/dd/yy)
Male
37. EMPLOYEE USUALLY WORKS
37a. EMPLOYMENT STATUS
37b. UNDER WHAT CLASS CODE
OF YOUR POLICY WERE WAGES
hours per day,
days per week,
total weekly hours
regular, full time
part-time
ASSIGNED?
EXTENT OF
temporary
seasonal
38. GROSS WAGES/SALARY
39. OTHER PAYMENTS NOT REPORTED AS WAGES/SALARY (e.g. tips, meals,
$
per
overtime, bonuses, etc.)?
Completed By (type or print)
Signature & Title
Date (mm/dd/yy)
*Confidential information may be disclosed only to the employee, former employee, or their personal representative (CCR Title 8 14300.35), to others for the purpose of processing a workers' compensation or other insurance claim: and under certain circumstances to a public health or law enforcement agency or to a consultant hired by the employer (CCR Title 8 14300.30). CCR Title 8 14300.40 requires provision upon request to certain state and federal workplace safety agencies.
FORM 5020 (Rev7) June 2002
FILING OF THIS FORM IS NOT AN ADMISSION OF LIABILITY
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