Summary of Employer Notice/Filing Requirements

For

Workers’ Compensation Claims

The District is permitted by statute to treat certain work related injuries as a first aid claim.  A First Aid Claim is defined as any one-time treatment, and any follow-up visit for the purpose of observation of minor scratches, cuts, burns, splinters, and so forth, which do not ordinarily require medical care. 

NOTE:  First aid claims do not require the completion of a Form 5020 (5020 in WORD) or DWC-1.  The employer refers the employee to the medical provider for care and reimburses the medical care provider directly.  If the injury results in continuing care beyond what was originally expected or if prescription medications are dispensed, then the claim is converted to a Workers' Compensation claim.  As a result, the employee completes a DWC-1 and the employer submits a 5020 form (5020 in WORD).

 Employer’s Report of Occupational Injury Or Illness Form 5020:  (5020 in WORD) must be completed when an occupational injury or illness results in “lost time” beyond the date of injury and/or requires medical treatment beyond “First Aid”.

     “Lost Time”:     Absence of work for a full day or shift beyond date of injury.

This form must be submitted within 5 days of the employer’s knowledge or notification to

LWP Claims Solutions, Inc. at 3835 N. Freeway Blvd. Suite 210, Sacramento, CA  95334

Employee’s Claim For Workers’ Compensation Benefits (DWC-1) Form:  Must be provided and processed as follows:

The form must be provided to the employee within 1 working day of receiving notice or knowledge of a work-related injury or illness;

Þ        To the employee personally

                        Þ        Sent by first class mail

     Upon receipt of a completed form, the district must date the form, provide a copy to the employee and

LWP Claims Solutions within 1 working day.