State of California

EMPLOYER'S REPORT OF OCCUPATIONAL INJURY OR ILLNESS

Any person who makes or causes to be made any knowingly false or fraudulent material statement or material representation for the purpose to 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.

FATALITY

EMPLOYER

1. FIRM NAME (Required)	1A. Policy Number
2. MAILING ADDRESS (Number and Street, City, ZIP) (Required)	2A. Phone Number (Required)
3. LOCATION If different from Mailing Address (Number And Street, City, ZIP)	3A. Location Code
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 Dist. Other Government, Specify:

INJURY OR ILLNESS

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

20a. COUNTY

21. ON EMPLOYER'S PREMISES?

Yes No

22. DEPARTMENT WHERE EVENT OR EXPOSURE OCCURRED, e.g., Shipping department, machine shop.	23. Other Workers Injured/Ill in this event? Yes No
24. EQUIPMENT, MATERIALS AND CHEMICALS THE EMPLOYEE WAS USING WHEN EVENT OR EXPOSURE OCCURRED, e.g., Acetylene, welding torch, farm tractor, scaffold:
25. SPECIFIC ACTIVITY THE EMPLOYEE WAS PERFORMING WHEN EVENT OR EXPOSURE OCCURRED, e.g., Welding seams of metal forms, loading boxes onto truck.
26. HOW INJURY/ILLNESS OCCURRED. DESCRIBE SEQUENCE OF EVENTS. SPECIFY OBJECT OR EXPOSURE WHICH DIRECTLY PRODUCED THE INJURY/ILLNESS, e.g., Worker stepped back to inspect work and slipped on scrap material. As he fell, he brushed against fresh weld, and burned right hand.

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

27a. PHONE NUMBER

28. HOSPITALIZED AS AN INPATIENT OVERNIGHT?
If yes, then, NAME AND ADDRESS OF HOSPITAL (Number, Street, City, Zip).

28a. Phone Number

29. Employee treated in Emergency Room?

Yes No

EMPLOYEE

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. See CCR Title 8 14300.29 (b)(6)-(10) & 14300.35(b)(2)(E)2. Note: Shaded boxes indicated confidential employee information as listed in CCR Title 8 14300.35(b)(2)(E)2.*
30. EMPLOYEE NAME (Required)	31. SOCIAL SECURITY NUMBER	32. DATE OF BIRTH (mm/dd/yy)
33. HOME ADDRESS (Number, Street, City, Zip)		33a. PHONE NUMBER
34. SEX Male Female	35. OCCUPATION (Regular job title, NO initials, abbreviated or numbers)	36. DATE OF HIRE (mm/dd/yy)
37. EMPLOYEE USUALLY WORKS hours per day, days per week, total weekly hours	37a. EMPLOYMENT STATUS	37b. UNDER WHAT CLASS CODE OF YOUR POLICY WERE WAGES ASSIGNED?
38. GROSS WAGES/SALARY $ per	39. OTHER PAYMENTS NOT REPORTED AS WAGES/SALARY (e.g. tips, meals, overtime, bonuses, etc.)? Yes No

Completed By (type or print)

Signature & Title

*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.

7. DATE OF INJURY/ONSET OF ILLNESS (mm/dd/yy) (Required)	8. TIME OF INJURY/ILLNESS OCCURRED AM PM	9. TIME EMPLOYEE BEGAN WORK AM PM	10. IF EMPLOYEE DIED, DATE OF DEATH (mm/dd/yy)
11. UNABLE TO WORK FOR AT LEAST ONE FULL DAY AFTER DATE OF INJURY ? Yes No	12. DATE LAST WORKED (mm/dd/yy)	13. DATE RETURNED TO WORK (mm/dd/yy)	14. IF STILL OFF WORK, CHECK THIS BOX:
15. PAID IN FULL DAYS WAGES FOR DATE OF INJURY OR LAST DAY WORKED? Yes No	16. SALARY BEING CONTINUED? Yes No	17. DATE OF EMPLOYER’S KNOWLEDGE / NOTICE OF INJURY/ILLNESS (mm/dd/yy) (Required)	18. DATE EMPLOYEE WAS PROVIDED CLAIM FORM (mm/dd/yy)
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.