Form 5020 California PDF Details

Are you familiar with the Form 5020 California? If you're a business owner or tax professional in the Golden State, you should be. This form is used to report information about certain types of taxable transactions. Here's what you need to know about it.

This page provides information regarding form 5020 california. It is definitely worth finding the time to read this before you start submitting your document.

QuestionAnswer
Form NameForm 5020 California
Form Length1 pages
Fillable?Yes
Fillable fields49
Avg. time to fill out10 min 7 sec
Other namesadsfadf, 33a, 28a, OSHA

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

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Provide the appropriate details in Yes, SALARYBEINGCONTINUED, Yes, SEX, AGE, aCOUNTY, ONEMPLOYERSPREMISES, Yes, DAILYHOURS, OtherWorkersInjuredIllinthisevent, Yes, Yes, aPhoneNumber, aPhoneNumber, and EmployeetreatedinEmergencyRoom segment.

Finishing SeaBright step 2

Mention the important information in EMPLOYEE, EMPLOYEENAME, HOMEADDRESSNumberStreetCityZip, SEX, Male, Female, aEMPLOYMENTSTATUS, regularfulltimetemporary, parttimeseasonal, SOCIALSECURITYNUMBER, DATEOFBIRTHmmddyy, EVENT, aPHONENUMBER, SECONDARY, and SOURCE area.

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