In addition to the Workers’ Compensation Employee Claim Form (DWC-1), the employer must provide a Facts for Injured Workers Sheet and a copy of the Medical Provider Network (MPN), (Employee Notification of Rights – Eng/Span). The appropriate supervisor should complete the Supervisors’ Report of Accident/Injury Form. To locate these forms visit the Resources page here.

If the employee seeks medical treatment, an Employer Report of Injury Form 5020 must be completed in order for the claim to be set up through Acclamation Insurance Management Services (AIMS). This can be completed through their online reporting system.

The employer should send all forms to AIMS and should a copy for their records. If you employee seeks treatment, please instruct your employee to return the Work Status Form they receive from the clinic.

Work Status Report
If the employee is placed on modified duty, the employee should be given a Report to Work letter to document the job offered. If the employee accepts the job and returns to work, he/she should be given an Employee Responsibilities Agreement to read and sign.

Posting & Employee Notification Requirements

You are required to post an Employer posting on Workers’ Compensation (DWC-7) in a conspicuous location.

Labor Code Section 3550 states that every employer shall post and keep posted in a conspicuous location frequented by employees, and where the notice may be easily read by employees during the hours of the workday, a notice which shall state that the employer is self-insured and the name of the claims administrator.

Failure to post the required notices in a conspicuous place shall automatically allow an employer to treat with his or her personal physician for an injury occurring while the notices are not posted.

The posters are just one way of communicating to your employees the location of the pre-designated treatment facility. The notice shall also include information about where and how to get emergency medical treatment as well as medical treatment, benefits, right to select and change treating physicians, and to whom an injury should be reported. All new hires should be advised where this information is posted and understand what the procedures are in case of an injury.

You are required to provide information about Right, Benefits and Obligations of Workers’ Compensation to every new employee.

Labor Code Section 3551 states that every employer shall provide to every new employee, either at the time of hire or no late than the end of the first pay period, information concerning the rights, benefits, and obligations under Worker’s Compensation laws.

The pamphlet shall be in writing, in non-technical terms, and shall include information regarding the scope of coverage, their rights to medical care, indemnity benefits, and vocational rehabilitation, the procedures for reporting accidents and injuries, and where additional information can be obtained.

Important Documents

To help you through the Workers' Compensation Program

COVID-19 and Workers Compensation Claims

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Facts about Workers’ Comp Pamphlet English

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Facts about Workers’ Comp Pamphlet Spanish

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Employee Notification for Rights – MPN Spanish 2019

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Employee Notification of Rights MPN 2019

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Employers Report of Injury Form 5020

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Report to Work Letter – Sample

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Employee Responsibilities

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Employer Posting DWC-7 JAN 2016 SIG

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