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Blank 5020 California PDF Form

The 5020 California form is the Employer's Report of Occupational Injury or Illness, which employers in California must complete when an employee experiences a work-related injury or illness. This form is essential for reporting incidents that lead to lost time or require medical treatment beyond first aid. Employers are required to submit this report within five days of becoming aware of the incident to ensure compliance with state regulations.

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Article Guide

The 5020 California form, officially known as the Employer's Report of Occupational Injury or Illness, serves as a crucial tool for employers in the state of California. This form is designed to document any occupational injuries or illnesses that employees may experience while on the job. Employers are required to complete this form in triplicate, ensuring that two copies are sent to SeaBright Insurance Company within five days of becoming aware of the incident. The form captures essential details, including the nature of the injury, the date it occurred, and the medical treatment required. It also prompts employers to report any fatalities or serious injuries immediately to the California Division of Occupational Safety and Health. By providing a structured way to report these incidents, the 5020 form helps maintain workplace safety and compliance with state regulations. The information collected not only aids in processing workers' compensation claims but also contributes to broader efforts to prevent future workplace injuries. Understanding how to accurately fill out this form is vital for employers, as any false statements can lead to serious legal repercussions.

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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: [email protected]

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

this column

2. MAILING ADDRESS: (Number, Street, City, Zip)

2a. Phone Number

CASE NUMBER

3. LOCATION if different from Mailing Address (Number, Street, City and Zip)

3a.Location Code

OWNERSHIP

4. NATURE OF BUSINESS; e.g.. Painting contractor, wholesale grocer, sawmill, hotel, etc.

5. State unemployment insurance

acct. no.

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)

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

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)

WORKED?

Yes

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

20. LOCATION WHERE EVENT OR EXPOSURE OCCURRED (Number, Street, City, Zip)

20a. COUNTY

21. ON EMPLOYER'S PREMISES?

DAILY HOURS

Yes

22. DEPARTMENT WHERE EVENT OR EXPOSURE OCCURRED, e.g.. Shipping department, machine shop.

23. Other Workers Injured/Ill in this event?

Yes

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.

I	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 27. NAME AND ADDRESS OF PHYSICIAN (Number, Street, City, Zip)

27a. Phone Number

NATURE OF

INJURY

28. HOSPITALIZED AS AN INPATIENT OVERNIGHT?

Yes

28a. Phone Number

If yes then, NAME AND ADDRESS OF HOSPITAL (Number, Street, City, Zip).

PART OF BODY

29. Employee treated in Emergency Room?

Yes

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

SOURCE

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

INJURY

38. GROSS WAGES/SALARY

39. OTHER PAYMENTS NOT REPORTED AS WAGES/SALARY (e.g. tips, meals,

per

overtime, bonuses, etc.)?

Yes

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

➤ PDF File

Form Specifications

Fact Name	Description
Purpose	The 5020 California form is used to report occupational injuries or illnesses to the employer's insurance company.
Submission Requirement	Employers must complete this form in triplicate and send two copies to SeaBright Insurance Company.
Governing Law	This form is governed by California Code of Regulations, Title 8, Sections 14300.29 and 14300.35.
Reporting Timeline	Employers are required to report injuries or illnesses within five days of becoming aware of them.
Amended Reports	If an employee dies due to a reported injury, an amended report must be filed within five days.
Confidentiality	The form contains confidential employee information, which must be protected during use.
Emergency Reporting	Serious injuries must be reported immediately by phone or telegraph to the California Division of Occupational Safety and Health.
False Statements	Making false statements on this form can result in felony charges under California law.

5020 California: Usage Guidelines

Filling out the 5020 California form requires attention to detail, as it is essential for reporting occupational injuries or illnesses. After completing the form, you will need to submit two copies to SeaBright Insurance Company and keep one for your records. Be sure to provide accurate information to avoid delays in processing.

Firm Name: Enter the name of your business.
Policy Number: Fill in your insurance policy number. Do not use the column marked with an "E."
Mailing Address: Provide the complete mailing address, including street, city, and zip code.
Phone Number: Enter a contact phone number.
Location: If different from the mailing address, provide the location where the incident occurred.
Ownership: Indicate the ownership type (e.g., private, state, county, city, school district, or other government).
Nature of Business: Describe the type of business (e.g., painting contractor, hotel).
Type of Employer: Check the appropriate box to indicate the type of employer.
Date of Injury/Onset of Illness: Enter the date the injury or illness occurred (mm/dd/yy).
Time Injury/Illness Occurred: Specify the time the injury or illness occurred (AM/PM).
Time Employee Began Work: Record the time the employee started work on that day (AM/PM).
Date of Death: If applicable, enter the date of the employee's death (mm/dd/yy).
Unable to Work For: Indicate the number of days the employee is unable to work.
Date Last Worked: Enter the last date the employee worked (mm/dd/yy).
Date Returned to Work: If applicable, enter the date the employee returned to work (mm/dd/yy).
Still Off Work: Check "Yes" or "No" if the employee is still off work.
Paid Full Day's Wages: Indicate whether full day’s wages were paid for the day of the injury.
Salary Being Continued: Check "Yes" or "No" regarding salary continuation.
Date of Employer's Knowledge: Enter the date the employer became aware of the injury (mm/dd/yy).
Date Employee Provided Claim Form: Enter the date the claim form was given to the employee (mm/dd/yy).
Specific Injury/Illness: Describe the injury or illness and the affected body part.
Location of Event: Provide the address where the injury or exposure occurred.
On Employer's Premises: Check "Yes" or "No" if the event occurred on employer's premises.
Department: Specify the department where the event occurred.
Other Workers Injured: Indicate if there were other workers injured in the same event.
Equipment/Materials Used: List the equipment or materials involved in the incident.
Specific Activity: Describe the activity the employee was performing at the time of the injury.
How Injury/Illness Occurred: Provide a detailed description of how the injury or illness happened.
Name and Address of Physician: Enter the physician's name and address.
Hospitalized Overnight: Check "Yes" or "No" regarding hospitalization.
Emergency Room Treatment: Indicate if the employee was treated in an emergency room.
Employee Name: Fill in the employee's full name.
Social Security Number: Provide the employee's social security number.
Date of Birth: Enter the employee's date of birth (mm/dd/yy).
Home Address: Provide the employee's home address.
Phone Number: Enter the employee's contact phone number.
Sex: Check the appropriate box for male or female.
Occupation: Write the employee's job title without abbreviations.
Date of Hire: Enter the date the employee was hired (mm/dd/yy).
Employee Usual Work Hours: Specify hours per day, days per week, and total weekly hours.
Employment Status: Indicate whether the employee is regular, full-time, part-time, temporary, or seasonal.
Gross Wages/Salary: Enter the employee's gross wages or salary.
Other Payments: Indicate if there were other payments not reported as wages.
Completed By: Type or print the name of the person completing the form, along with their signature and title.
Date: Enter the date the form was completed (mm/dd/yy).

Your Questions, Answered

What is the purpose of the 5020 California form?

The 5020 California form is designed for employers to report occupational injuries or illnesses that occur in the workplace. It serves as a formal record of incidents that result in lost time or require medical treatment beyond first aid. This form is crucial for ensuring compliance with state regulations regarding workplace safety and workers' compensation claims.

Who needs to complete the 5020 form?

Employers in California are required to complete the 5020 form whenever an employee experiences an occupational injury or illness that meets specific criteria. This includes cases where the employee misses work or needs medical treatment beyond first aid. Additionally, if an employee dies as a result of a previously reported injury or illness, an amended report must be filed.

How soon must the form be submitted after an incident?

Employers must submit the 5020 form within five days of learning about the occupational injury or illness. This prompt reporting is essential to comply with California law and to facilitate the processing of workers' compensation claims.

Where should the completed form be sent?

After completing the 5020 form, employers must mail two copies to SeaBright Insurance Company at their designated address: PO Box 11027, Orange, CA 92856-8127. Alternatively, the form can be faxed to (714) 918-5972 or emailed to [email protected].

What information is required on the form?

The 5020 form requires various details, including the employer's name, policy number, mailing address, and specifics about the employee and the incident. This includes the date and time of the injury, the nature of the injury, and any medical diagnosis if available. Employers must also provide information about the employee's work status and any treatments received.

Is the information on the 5020 form confidential?

Yes, the information contained in the 5020 form is sensitive and must be handled with care. Employers are required to protect the confidentiality of the employee's health information. Disclosure is limited to the employee, their personal representative, or for processing workers' compensation claims, as stipulated by California regulations.

What happens if an employer fails to file the form on time?

Failing to file the 5020 form within the required timeframe can lead to penalties and complications in the workers' compensation process. Employers may face legal repercussions for not adhering to reporting requirements, which can impact their liability and insurance claims.

Can the form be amended after submission?

If an employer discovers additional information or if the situation changes—such as the employee's death due to the reported injury—they must file an amended report within five days of gaining that knowledge. This ensures that all relevant information is accurately reflected in the records.

What should be done if the injury results in a serious incident?

In the event of a serious injury, illness, or death, employers must report the incident immediately by telephone or telegraph to the nearest office of the California Division of Occupational Safety and Health. This immediate reporting is crucial for regulatory compliance and workplace safety oversight.

Common mistakes

Incomplete Information: Failing to fill out all required fields can lead to delays in processing the report. Each section of the form is crucial for a complete understanding of the incident.
Incorrect Dates: Entering the wrong dates for the injury, last worked day, or return to work can cause confusion. Ensure that all dates are accurate and formatted correctly.
Vague Descriptions: Providing unclear or generic descriptions of the injury or illness may hinder the claims process. Be specific about the nature of the injury and the circumstances surrounding it.
Neglecting Confidentiality: Sharing sensitive employee information improperly can lead to legal issues. Always handle the form with care, ensuring that confidential details are protected according to regulations.

Documents used along the form

When dealing with workplace injuries or illnesses in California, the 5020 California form is a crucial document. However, there are several other forms and documents that are often used in conjunction with it. Understanding these can help ensure that all necessary steps are taken for compliance and proper handling of claims.

Claim Form (DWC 1): This form is used by employees to officially report a work-related injury or illness to their employer. It provides essential details about the incident and is necessary for initiating a workers' compensation claim.
Employer's First Report of Injury (FROI): Similar to the 5020 form, this document is filed by employers to report the details of an employee's injury or illness. It serves as an initial notification to the insurance carrier and includes critical information about the incident.
Medical Authorization Form: This form allows employers or insurance companies to obtain medical records related to the employee's injury or illness. It ensures that the necessary medical information can be accessed for claim processing.
Return-to-Work Form: After an employee has been injured, this form is used to document their ability to return to work. It often requires a medical professional's approval and outlines any work restrictions.
Subrogation Agreement: In cases where a third party may be liable for the injury, this agreement allows the employer or insurance company to pursue compensation from that third party. It is essential for protecting the employer's interests.
Incident Report: This internal document details the circumstances of the injury or illness, including witness statements and environmental factors. It is crucial for understanding the context of the incident and may be used for future safety improvements.
OSHA Report: If the injury is severe, an OSHA report may be required. This document is submitted to the Occupational Safety and Health Administration and helps in tracking workplace safety trends and compliance.

Using the 5020 form alongside these additional documents can help ensure that all aspects of a workplace injury or illness are properly addressed. By being thorough in documentation and reporting, employers can better navigate the complexities of workers' compensation claims.

Similar forms

The California Form 5020, which serves as an employer's report of occupational injury or illness, shares similarities with several other important documents related to workplace injuries and workers' compensation. Each of these forms plays a crucial role in ensuring that injuries are reported and managed appropriately. Below is a list of documents that are similar to the 5020 form, along with explanations of their similarities.

OSHA Form 300: This form is used to log work-related injuries and illnesses. Like the 5020, it requires detailed information about the incident, including the nature of the injury and the circumstances surrounding it.
California DWC Form 1: This is the "Employee's Claim for Workers' Compensation Benefits" form. It is similar to the 5020 in that it initiates the workers' compensation process, allowing employees to formally report their injuries and seek benefits.
California DWC Form 5021: This form is the "Employer's Report of Injury" and serves a similar purpose to the 5020. It is used to report workplace injuries to the workers' compensation insurance carrier and requires similar information about the incident.
California DWC Form 300: This is another variant of the injury report form that employers can use to document work-related injuries. It parallels the 5020 in its focus on the details of the injury and the employee's condition.
First Report of Injury (FROI): This document is used across various states to report workplace injuries. It shares the same goal as the 5020, ensuring that injuries are documented and that the necessary parties are informed promptly.
Incident Report Form: Many employers use this form to document accidents in the workplace. Like the 5020, it captures details about the incident, including what happened, where it occurred, and any injuries sustained.
Workers' Compensation Claim Form: This form is essential for employees seeking compensation for work-related injuries. It is similar to the 5020 in that it requires comprehensive information about the injury and its impact on the employee's ability to work.
Return-to-Work Form: This document is used to assess an employee's readiness to return to work after an injury. It complements the 5020 by ensuring that employers are informed about the employee's recovery and any restrictions they may have.

Each of these documents plays a vital role in the workers' compensation system, ensuring that injuries are reported, tracked, and managed effectively. Understanding their similarities can help employers and employees navigate the complexities of workplace injuries more efficiently.

Dos and Don'ts

When filling out the 5020 California form, it is essential to follow specific guidelines to ensure accuracy and compliance. Here are ten things to keep in mind:

Do complete the form in triplicate, ensuring you have enough copies for submission.
Don't submit the form without checking for completeness; missing information can delay processing.
Do use clear and legible handwriting or type the information if possible.
Don't use initials, abbreviations, or numbers for job titles; provide full titles instead.
Do report the injury or illness within five days of knowledge, as required by California law.
Don't provide false or misleading information; this could lead to serious legal consequences.
Do specify the exact nature of the injury or illness, including the part of the body affected.
Don't forget to include the date of injury and the employee's last day worked.
Do ensure that you provide accurate contact information for the employee and the physician.
Don't overlook the need to report any serious injuries immediately by phone or telegraph to the California Division of Occupational Safety and Health.

Misconceptions

Understanding the 5020 California form is crucial for employers dealing with workplace injuries and illnesses. However, several misconceptions exist regarding this form. Below is a list of common misunderstandings, along with clarifications.

Filing the form is optional. Many believe that submitting the 5020 form is optional. In reality, California law mandates employers to report occupational injuries or illnesses that lead to lost time or require medical treatment beyond first aid within five days of becoming aware of the incident.
Only serious injuries need to be reported. Some assume that only serious injuries require reporting. However, any injury or illness that results in lost time or necessitates medical treatment must be documented, regardless of its perceived severity.
Filing the form admits liability. There is a misconception that completing the 5020 form implies that the employer accepts liability for the injury. This is not true; filing the form is simply a procedural requirement and does not constitute an admission of fault.
All employee injuries must be reported immediately. While serious injuries must be reported immediately, not all injuries require immediate reporting. Only those that result in lost time or medical treatment beyond first aid need to be reported within five days.
The form only needs to be filled out if the employee is hospitalized. Some believe that the form is only necessary if the employee is hospitalized. In fact, the form must be completed for any injury or illness that leads to lost time or requires medical attention, regardless of hospitalization.
Confidential information is not protected. A common misunderstanding is that the information provided on the form lacks confidentiality. In truth, the form contains sensitive employee health information, and employers are required to handle this data in a manner that maintains confidentiality.

Clarifying these misconceptions can help ensure that employers comply with legal requirements and protect both their employees and themselves in the event of workplace injuries or illnesses.

Key takeaways

When filling out the 5020 California form, it is crucial to adhere to specific guidelines to ensure compliance and accuracy. Here are key takeaways:

Timeliness is Essential: Employers must report any occupational injury or illness within five days of becoming aware of it, especially if it results in lost time or requires medical treatment beyond first aid.
Accurate Information is Critical: Ensure all fields are filled out completely and accurately, including the nature of the business, date of injury, and specific details about the incident.
Confidentiality Must be Maintained: The form contains sensitive employee health information. It should be handled with care to protect the confidentiality of the employee involved.
Immediate Reporting of Serious Incidents: Any serious injury, illness, or death must be reported immediately by telephone or telegraph to the California Division of Occupational Safety and Health.