Employer Requirements

As an employer, you are required by law to provide your employees notice about their workers’ compensation benefits, MPN providers, and where to seek treatment for workers’ compensation injuries. State Fund policyholders can use the materials below to meet those obligations. The chart below lists the mandated materials and when employers should distribute them.

 

Required Materials	Policy Inception	Time of Hire	Time of Injury
Notice to Employees DWC 7 Notice to Employees DWC7 Must be posted at every worksite in a location that is easily visible to your employees. Must be posted in both English and Spanish where there are Spanish-speaking employees. Before posting the notice, enter the following information below: MPN  Office: www.dir.ca.gov/dwc/ianda.html
Employee’s Guide to The State Fund MPN by Harbor Health e3851(Replaces State Fund form e13176, English & Spanish) Must be provided to employee at time of injury or, where there is existing injury, and when transferring care into the MPN. Must be provided in both English and Spanish if the employee primarily speaks Spanish.
New Employee’s Guide to Workers’ Compensation e13286
Workers’ Compensation Claim Form e3301 with instructions
Employer’s Report of Occupational Injury or Illness e3067 Must be completed and submitted to State Fund no later than 5 days from the date of knowledge of a work injury or illness.

 

PENALTIES
Per Title 8 California Code of Regulations (CCR) section § 9881 all California Employers are required to display this poster at every worksite in a location that is easily visible to your employees. Must be posted in both English and Spanish where there are Spanish-speaking employees. Non-compliant employers face potential penalties up to $7,000.00.

 

Forms

Downloadable Forms

• Employer’s First Report of Injury
• Express Scripts Pharmacy Registration Form
• Marijuana/Cannabis Operations Supplemental Questionnaire
• Medical Mileage Expense Form
• Notice Of Temporary Staffing Client Letter
• Trucking Industry Workers’ Compensation Questionnaire
• Workers’ Compensation Claim Form (DWC 1)

Informational Materials

• ACORD 130 (Non-Broker Accounts) ACORD 130
• Deposit Payroll Reporting
• Electronic Premium Payment and Payroll Reporting
• Explanation of Insurance Surcharges
• For Brokers: Free Continuing Education Classes at State Fund 
• Information Sharing Disclosure (Privacy Policy)
• Requirements for Separate Classifications by Wage Level in the Construction Industry
• Premium Audit Guide
• Premium Audit Guide (Spanish)
• Reduce Claims Costs Through Timely Claims Reporting
• State Compensation Insurance Fund – California’s Workers’ Compensation Specialist
• State Fund Safety Services
• State Fund Value Statement for Brokers
• State Fund’s Financial Strength and Lasting Value
• Supplemental Application Form (SAF)
• Your Guide to the Alternative Dispute Resolution System
• Your Guide to Workers’ Compensation (English/Spanish)

Mandated Forms

• Employee’s Guide to the State Fund MPN by Harbor Health (English/Spanish)
• New Employee’s Guide to Workers’ Compensation (English/Spanish)
• Notice to Employees DWC 7

Waiver Forms to Elect Exclusions:

• Corporate Officers and Directors Waiver of Workers’ Compensation Coverage
• General Partners Waiver of Workers’ Compensation Coverage
• LLC Managing Members Waiver of Workers Compensation Coverage
• Coverage Questionnaire for Excluded Individuals

Medical Provider Forms

Informational Materials

• Request for Authorization DWC Form RFA