NO
State of California
EMPLOYER'S REPORT
OF OCCUPATIONAL
INJURY OR ILLNESS
STATE COMPENSATION INSURANCE FUND
CLAIMS REPORTING: Electronic First Report of Injury (EFROI) using your State Fund ID & Password
at: www.statefundca.com/statecontracts
or fax to the Customer Service Center at 800-371-5905
THIS FORM IS NOT TO BE VIEWED OR COMPLETED BY THE EMPLOYEE
PAGE 1 of 2
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.
NOTICE: 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
an amended report indicating death. In addition, every serious injury, illness, or death must be reported immediately
telephone or telegraph to the nearest office of the California Division of Occupational Safety and Health.
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1a. AGENCY CODE OR STATE FUND
POLICY NUMBER
not use this
Column
2. MAILING ADDRESS (Number and Street, City, Zip)
3. LOCATION, if different from Mailing Address (Number, Street, City and Zip)
4. NATURE OF BUSINESS; e.g., Painting contractor, wholesale grocer, sawmill, hotel, etc.
5. STATE UNEMPLOYMENT INSURANCE
ACCT. NO.
PRIVATE
X
STATE
COUNTY
CITY
SCHOOL DIST.
OTHER GOVERNMENT - SPECIFY
I
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J
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S
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7. DATE OF INJURY / ONSET OF ILLNESS
(mm/dd/yy)
8. TIME INJURY/ILLNESS OCCURRED
_______ A.M. _______ P.M.
9. TIME EMPLOYEE BEGAN WORK
_______ A.M. _______ P.M.
10. IF EMPLOYEE DIED, DATE OF DEATH
(mm/dd/yy)
11. UNABLE TO WORK FOR AT LEAST ONE
FULL DAY AFTER
DATE OF INJURY?
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 FULL DAY'S WAGES FOR DATE OF
INJURY OR LAST
DAY WORKED?
16. SALARY BEING CONTINUED?
YES
NO
17. DATE OF EMPLOYER'S KNOWLEDGE/
NOTICE OF INJURY/ILLNESS (mm/dd/yy)
18. DATE EMPLOYEE WAS PROVIDED
CLAIM FORM
(mm/dd/yy)
19. SPECIFIC INJURY/ILLNESS AND MEDICAL DIAGNOSIS if available, e.g., Second degree burns on right arm, tendonitis on left elbow, lead poisoning.
Week
20. LOCATION WHERE EVENT OR EXPOSURE OCCURRED (Address)
21. ON EMPLOYER'S PREMISES?
YES NO
RESPONSIBLE?
22. DEPARTMENT WHERE EVENT OR EXPOSURE OCCURRED, e.g., Shipping department, machine shop.
23. OTHER WORKERS INJURED OR 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. USE SEPARATE SHEET IF NECESSARY.
Injury
27. NAME AND ADDRESS OF PHYSICIAN (Number, Street, City, Zip)
28. HOSPITALIZED AS AN INPATIENT OVERNIGHT?
NO
YES If yes, then, NAME AND ADDRESS OF HOSPITAL (Number,
Street, City, Zip)
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 occupat
ional safety and health purposes. 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.*
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31. SOCIAL SECURITY NUMBER
32. DATE OF BIRTH (mm/dd/yy)
33. HOME ADDRESS (Number, Street, City, Zip)
MALE
FEMALE
35. OCCUPATION (Regular job title, NO initials, abbreviations or numbers)
36. DATE OF HIRE (mm/dd/yy)
Source
37. EMPLOYEE USUALLY WORKS
hours days total
_______ per day _______ per week _______ weekly hours
regular, full-time part-time retired on strike
temporary seasonal laid-off other
37b. UNDER WHAT CLASS CODE OF
YOUR POLICY WERE WAGES ASSIGNED?
$ ___________________ per __________________
39. OTHER PAYMENTS NOT REPORTED AS WAGES/SALARY (e.g., tips, meals, overtime,
bonuses, etc.)?
Injury
YES NO
41. CSID # (3 digit division, 4 digit position or job classification, 3 digit serial number)
Completed By (type or print)
(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.
e3067 (Rev. 03/20)
STATE
FILING OF THIS REPORT IS NOT AN ADMISSION OF LIABILITY. A CLAIM FORM MUST BE GIVEN TO THE INJURED WORKER WITHIN ONE
WORKING DAY OF YOUR KNOWLEDGE OF OCCUPATIONAL INJURY OR ILLNESS WHICH RESULTS IN LOST TIME OR MEDICAL TREATMENT.
NO
NO
