Smart Form 5020
     
 
State of California
EMPLOYER'S REPORT OF
OCCUPATIONAL INJURY OR ILLNESS
Please complete in triplicate (type if possible) Mail two copies to:
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.
 
 
Employer
 
 
1. Firm Name * 1a. Policy Number
 
 
2. Mailing Address
Address *    
     
City * State * Zip *
     
 
 
2a. Phone Number *
 
 
3. Location ( If different from mailing address 3a. Location Code
 
 
4. Nature of Business * 5. State unemployment insurance acct. no *
 
 
6. Type of Employer *
Private State County City School District Other Gov't. Specify:
                         
 
 
Injury or Illness
 
 
7. DATE OF INJURY / ONSET OF ILLNESS (mm/dd/yy) * 8. TIME INJURY/ILLNESS OCCURRED * 9. TIME EMPLOYEE BEGAN WORK * 10. IF EMPLOYEED DIED, DATE OF DEATH (mm/dd/yy)
Date Picker
Date Picker
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 box:
Yes No
Date Picker
Date Picker
15. PAID FULL DAYS WAGES FOR DATE OF INJURY OR LAST DAY WORKED? * 16. SALARY BEING CONTINUED? * 17. DATE OF EMPLOYER'S KNOWLEDGE/NOTICE OF INJURY/ILLNESS (mm/dd/yy) * 18. DATE EMPLOYEE WAS PROVIDED CLAIM FORM (mm/dd/yy) *
Yes No Yes No
Date Picker
Date Picker
 
 
19. SPECIFIC INJURY/ILLNESS AND PART OF BODY AFFECTED, MEDICAL DIAGNOSIS *
 
 
20. LOCATION WHERE EVENT OR EXPOSURE OCCURRED (Number, Street, City, Zip) * 20a. COUNTY *
21. ON EMPLOYER'S PREMISES? *
Address *
City * State * Zip *

Yes

No

 
 
22. DEPARTMENT WHERE EVENT OR EXPOSURE OCCURRED (Number, Street, City, Zip) * 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 *
 
 
25. SPECIFY ACTIVITY THE EMPLOYEE WAS PERFORMING WHEN EVENT OR EXPOSURE OCCURRED *
 
 
26. HOW INJURY/ILLNESS OCCURRED. DESCRIBE SEQUENCE OF EVENTS. SPECIFY OBJECT OR EXPOSURE WHICH DIRECTLY PRODUCEDTHE INJURY/ILLNESS *
 
 
27. Name and Address of Physician * 27a. Phone Number *
28. Hospitalized as an inpatient overnight?
28a. Phone Number
NO YES
(If yes then, name and address of hospital (number, street, city, zip)
Address
City State Zip
29. Employee treated at 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. See CRT 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*.
 
 
Employee
 
 
30. EMPLOYEE NAME * 31. SOCIAL SECURITY NUMBER * 32. DATE OF BIRTH (mm/dd/yy) *
Date Picker
 
 
33. HOME ADDRESS (Number, Street, City, Zip) * 33a. PHONE NUMBER *
Address *
City * State * Zip *
 
 
34. SEX * 35. OCCUPATION (Regular job title,NO initials, abbreviations or numbers) * 36. DATE OF HIRE (mm/dd/yy) *
Male Female
Date Picker
 
37. Employee Usually Works *
Hours per day.
Days per week.  
total weekly hours
37a. Emplyee Status *
Regular, Full-time
Part-time
Temporary
Seasonal
37b. UNDER WHAT CLASS CODE OF YOUR POLICY WHERE WAGES ASSIGNED
 
 
38. GROSS WAGES/SALARY * 39. OTHER PAYMENTS NOT REPORTED AS WAGES/SALARY (e.g. tips, meals, overtime, bonuses, etc.)? *
$ per Yes No
   
   
 
 
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 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