Form 5020-2025

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The document is the 'Employer's Report of Occupational Injury or Illness' for the State of California, which outlines the legal requirements for employers to report workplace injuries or illnesses. It mandates reporting within five days for incidents resulting in lost time or requiring medical treatment, and includes specific instructions on how to complete the form, including details about the injured employee, nature of the injury, and employer information. The document emphasizes the importance of accurate reporting and confidentiality.

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Where to send form 5020?

Electronic Reporting System for Doctors First Report of Injury. Every physician who treats an injured employee must file a complete Form 5021 Doctors First Report of Occupational Illness or Injury (DFR) with the employers claims administrator within five days of the initial examination.

Where do I mail form 5020?

Forward the original copy of the Form 5020, the accident investigation forms and the completed and signed DWC1 to WCD at 700 East Temple Street, Room 210, Los Angeles, CA 90012, Mail Stop 391, by fax at (213) 473-3333, or via email at per.wcdiv@lacity.org.

What is a 5021 form?

Employers must report any worker fatality within 8 hours and any amputation, loss of an eye, or hospitalization of a worker within 24 hours.

How long do you have to report a work injury in California?

As required by Title 8 regulations, section 342, you must include the following information in your phone call, if available: Time and date of accident/event. Employers name, address and telephone number. Name and job title of the person reporting the accident. Address of accident/event site.

What is the 5020 form?

FORM 5020 (PDF - 533kb)*: State of California EMPLOYERS REPORT OF OCCUPATIONAL INJURY OR ILLNESS. This form must be completed within 5 days of knowledge of an injury or illness.