If you have an employee testing positive for COVID-19, use this form to ensure you're in compliance with the latest California
legislation. We'll use information provided to determine if an outbreak occurred between 7/6/20 and 12/31/22, for the
purpose of applying presumption criteria.
For all reports:
DON'T include personal information about the employee - unless infection is work related or they’ve filed a claim.
Complete the below and send to:
(use the below Email button)
• OR fax: 858.436.8916
• OR call 877.442.9669 - we're happy to assist!
SB 1159 Reporting Information
1) Please check one. Note reporting date requirements and information about specific place of employment.*
* “Specific place of employment” means building, store, facility or agricultural field where employee performed work at employer’s
direction. Does not include employee’s home or residence, unless employee provides home health care services to another individual at
employee’s home or residence.
My Employee tested positive for COVID-19 PRIOR to 9/17/20 - Report within 30 business days or before 10/29/20.
If between 7/6/20 - 9/16/20, highest number of employees who reported to work at each of employee’s specific
places of employment on any given work day between 7/6/20 - 9/17/20: __________________________________
My Employee tested positive for COVID-19 on or AFTER 9/17/20 - Report within 3 business days of knowledge.
Highest number of employees reporting to work at employee’s specific place of employment in 45-day period
preceding last day employee worked at each specific place of employment: ________________________________
2) Company: _________________________________________________________ Policy number: ___________________
3) Employer’s date of knowledge*: ___________________
* Or, date reasonably should have known employee tested positive.
4) If employee asserts work-related infection or has filed claim, please add employee’s name or unique identifier*:
* If not, DON’T provide any personally identifiable information regarding employee who tested positive for COVID-19.
5) Date employee took COVID-19 test resulting in a “positive”*: ________________________________________________
* “COVID-19 test” is defined as Polymerase Chain Reaction (PCR) test approved for use or approved for emergency use by U.S. Food and
Drug Administration to detect the presence of viral RNA. A “COVID-19 test” does not include serologic testing, also known as antibody
testing. Further, “COVID-19 test” may include any other viral culture test, approved for use or approved for emergency use by U.S. Food
and Drug Administration to detect presence of viral RNA, having same or higher sensitivity and specificity as PCR Test.
6) Last date employee worked at place of employment at employer’s direction: ____________________________________
7) Specific address(es) of employee’s specific place of employment during 14-day period preceding date of employee’s
positive test: _______________________________________________________________________________________
8) Yes No - The above specific place of employment has been ordered closed by local public health department,
State of Department of Public Health, Division of Occupational Safety and Health, or school superintendent due to risk of
infection with COVID-19.
9) Person completing this report:
Name: __________________________________________Title: ________________________________ Date: ___________
Disclaimer – An employer or other person acting on behalf of an employer who intentionally submits false or misleading information or fails
to submit information when reporting is subject to a civil penalty in the amount of up to ten thousand dollars ($10,000) to be assessed by the
Labor Commissioner. If upon inspection or investigation, the Labor Commissioner determines an employer or other person has intentionally
submitted false or misleading information, the Labor Commissioner may issue a citation to the person in violation.
ICW Group includes Insurance Company of the West and Explorer Insurance Company v092020
SB 1159 California Employer
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