Form 5020 California – Fill Out and Use This PDF

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

I

WEEKLY WAGE

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)

FORM 5020 (Rev7) June 2002

FILING OF THIS FORM IS NOT AN ADMISSION OF LIABILITY