Submit this form at mwiaadministrators.com
Phone: (800) 936-0384
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.
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6. TYPE OF EMPLOYER:
City
School District
Private
County
State
Other Gov't, Specify:
17. DATE OF EMPLOYER'S KNOWLEDGE /NOTICE OF
INJURY/ILLNESS (mm/dd/yy)
1
8. DATE EMPLOYEE WAS PROVIDED CLAIM FORM
15.
PAID FULL DAYS WAGES FOR DATE OF
SEX
16. SALARY BEING CONTINUED?
NJURY OR LAST
FORM (mm/dd/yy)
Yes
No
DAY WORKED?
Yes
No
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
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Y
21. ON EMPLOYER'S PREMISES?
20a. COUNTY
20. LOCATION WHERE EVENT OR EXPOSURE OCCURRED (Number, Street, City, Zip)
Yes
No
22. DEPARTMENT WHERE EVENT OR EXPOSURE OCCURRED, e.g.. Shipping department, machine shop. 23. Other Workers injured or ill in this event?
Yes
No
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N
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PART OF BODY
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. 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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35. OCCUPATION (Regular job title, NO initials, abbreviations or numbers)
37b. UNDER WHAT CLASS CODE OF YOUR
POLICY WHERE WAGES ASSIGNED
37a. EMPLOYMENT STATUS
37. EMPLOYEE USUALLY WORKS
regular, full-time
part-time
EXTENT OF INJURY
total weekly hours
days per week,
hours per day,
temporary
seasonal
39. OTHER PAYMENTS NOT REPORTED AS WAGESISALARY (e.g. tips, meals, overtime, bonuses, etc.)?
38. GROSS WAGES/SALARY
per
$
Yes
N
o
Date (mm/dd/yy)
Signature & Title
Completed By (type or print)
• 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 insuranc
e
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
OSHA CASE NO.
FATALITY
1. FIRM NAME
Ia. Policy Number
2. MAILING ADDRESS: (Number, Street, City, Zip)
2a. Phone Number
3. LOCATION if different from Mailing Address (Number, Street, City and Zip)
3a. Location Code
4. NATURE OF BUSINESS; e.g.. Painting contractor, wholesale grocer, sawmill, hotel, etc.
5. State unemployment insurance acct.no
Please do not use
this column
CASE NUMBER
OWNERSHIP
INDUSTRY
OCCUPATION
7. DATE OF INJURY / ONSET OF ILLNESS
(mm/dd/yy)
8. TIME INJURY/ILLNESS OCCURRED
PM
AM
9. TIME EMPLOYEE BEGAN WORK
PM
AM
10. IF EMPLOYEE DIED, DATE OF DEATH (mm/dd/yy)
1 1. UNABLE TO WORK FOR AT LEAST ONE
FULL DAY AFTER DATE OF INJURY?
Yes No
12. DATE LAST WORKED (mm/dd/yy)
13. DATE RETURNED TO WORK (mm/dd/yy)
14. IF STILL OFF WORK, CHECK THIS BOX:
DAILY HOURS
DAYS PER WEEK
WEEKLY HOURS
WEEKLY WAGE
COUNTY
NATURE OF INJURY
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 INJURYIILLNESS, 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
SOURCE
EVENT
SECONDARY SOURCE
State of California
EMPLOYER'S REPORT OF
OCCUPATIONAL INJURY OR ILLNESS
27. Name and address of physician (number, street, city, zip)
28. Hospitalized as an inpatient overnight?
If yes then, name and address of hospital (number, street, city, zip)
29. Employee treated in emergency room?
31. SOCIAL SECURITY NUMBER
32. DATE OF BIRTH (mm/dd/yy)
33. HOME ADDRESS (Number, Street, City,Zip)
36. DATE OF HIRE (mm/dd/yy)
