Form 5020 California PDF Details

Navigating the complexities of workplace safety obligations, the 5020 California Form stands as a critical document for employers within the state, encapsulating the stringent reporting requirements set forth by California law. This form, known as the Employer's Report of Occupational Injury or Illness, must be completed meticulously and submitted promptly—within five days when an occupational injury or illness results in lost time beyond the day of the incident or necessitates medical treatment beyond first aid. The form plays a key role in the realm of workers' compensation, providing crucial details such as the nature of the business, specifics of the injury or illness, and the circumstances under which the event occurred. It underscores the legal mandate for immediate reporting to the California Division of Occupational Safety and Health in cases of severe injuries, illnesses, or death. Compliance with this requirement not only aids in the facilitation of workers' compensation benefits but also serves as a measure of prevention and correction, ensuring a safer workplace environment. Employers are reminded of the severe implications for knowingly making false or fraudulent statements related to workplace injuries, illustrating the form's pivotal role in maintaining transparency and accountability. Additionally, its proviso of information regarding employee confidentiality highlights a careful balance between occupational safety and employee privacy. The 5020 Form embodies the shared responsibility between employers and regulatory bodies to uphold worker health and safety as paramount.

QuestionAnswer
Form NameForm 5020 California
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other names33a, po box 11027 orange ca, false, seabright insurance po box 11027

Form Preview Example

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: ca-claims@sbic.com

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

E

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

this column

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2a. Phone Number

 

M

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

P

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CASE NUMBER

L

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

 

 

 

 

 

 

 

 

 

3a.Location Code

 

O

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OWNERSHIP

Y

 

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

 

 

 

 

 

5. State unemployment insurance

 

E

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

acct. no.

 

 

 

R

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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)

 

 

 

 

 

 

 

 

 

 

 

AM

 

 

PM

 

 

 

AM

 

 

PM

 

 

 

 

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

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I

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)

 

N

WORKED?

Yes

No

 

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

J

 

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

U

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

R

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Y

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

 

20a. COUNTY

 

 

 

 

 

21. ON EMPLOYER'S PREMISES?

DAILY HOURS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

O

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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:

 

 

 

R

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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.

N

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

COUNTY

E

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

S

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

27a. Phone Number

 

 

 

NATURE OF

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INJURY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

28. HOSPITALIZED AS AN INPATIENT OVERNIGHT?

 

 

Yes

 

 

No

 

 

 

 

 

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

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

E

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SECONDARY

M

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SOURCE

P

34. SEX:

Female

35. OCCUPATION ( Regular job title, NO initials, abbreviations or numbers)

 

 

 

 

 

 

 

36. DATE OF HIRE (mm/dd/yy)

 

 

 

 

 

 

 

 

 

 

L

 

Male

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

O

37. EMPLOYEE USUALLY WORKS

 

 

 

 

 

 

 

 

 

 

 

 

37a. EMPLOYMENT STATUS

 

 

 

 

 

37b. UNDER WHAT CLASS CODE

 

 

Y

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OF YOUR POLICY WERE WAGES

 

 

 

 

 

hours per day,

 

 

days per week,

total weekly hours

regular, full time

part-time

 

ASSIGNED?

 

EXTENT OF

E

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

temporary

 

seasonal

 

 

 

 

 

INJURY

E

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

38. GROSS WAGES/SALARY

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

$

 

per

 

 

 

 

 

 

 

overtime, bonuses, etc.)?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

How to Edit Form 5020 California Online for Free

The whole process of filling out the adsfadf is rather effortless. Our team made sure our PDF tool is not hard to navigate and helps fill out any sort of document within minutes. Listed here are a couple of steps you'll want to take:

Step 1: Press the "Get Form Now" button to get started on.

Step 2: As soon as you get into the adsfadf editing page, you'll see each of the functions you may take with regards to your file within the top menu.

Type in the essential details in each segment to fill in the PDF adsfadf

example of fields in seabright insurance po box 11027

Provide the appropriate details in Other Workers InjuredIll in this, Yes, EQUIPMENT MATERIALS AND CHEMICALS, SPECIFIC ACTIVITY THE EMPLOYEE, HOW INJURYILLNESS OCCURRED, NAME AND ADDRESS OF PHYSICIAN, HOSPITALIZED AS AN INPATIENT, Yes, a Phone Number, a Phone Number, Employee treated in Emergency, Yes, ATTENTION This form contains, DAYS PER WEEK, and WEEKLY HOURS segment.

Finishing seabright insurance po box 11027 step 2

Mention the important information in GROSS WAGESSALARY per, Completed By type or print, Signature Title, OTHER PAYMENTS NOT REPORTED AS, Yes, Date mmddyy, E M P L O Y E E, Confidential information may be, FORM Rev June, and FILING OF THIS FORM IS NOT AN area.

Finishing seabright insurance po box 11027 part 3

Step 3: After you click the Done button, the finalized document is readily transferable to each of your devices. Alternatively, you can deliver it by using mail.

Step 4: Attempt to create as many duplicates of your document as you can to stay away from future worries.

Watch Form 5020 California Video Instruction

Form 5020 California isn’t the one you’re looking for?

Related Documents

  • Form 503

    "... Form 503 General Information Assumed Name Certificate The attached form was drafted in order to comply with minimal statutory filing requirements pursuant to relevant code provisions. Comment domestic or foreign corporation limited Liabi Lit company ..."

  • Form 50 244

    "... Texas comptroller for public accounts Form 50244 Dealer motor vehicle inventor declaration confidential General Instructions This declaration allows dealers of motor vehicles to file declarations for each location under tax code 23 121. The dealer ..."

  • Form 50 246

    "... Property tax form 50 246 Dealer motor vehicle inventory tax report confidential page of pages Reporting month year Send original to countytax office name, address code and number and a copy to appraisal district number. ..."

  • Form 5021

    "... State of California doctor, first report on occupational injury/illness within 7 days after your first examination. In the event of suspected or diagnosed pesticide poisoning, send two copies to the insurance company or insured employer. ..."

Please rate Form 5020 California

1 Votes

Related Resources

If you believe this page is infringing on your copyright, please familiarize yourself with and follow our DMCA notice and takedown process - click here to proceed .