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California

 

Workers Compensation Claims Kit

Report all work-related injuries or illnesses promptly. Keep in mind that reporting does not mean that you agree that the injury is legitimate, nor does it mean that the incident will be compensable under state workers’ compensation statutes.
3 Steps to Reporting a Work-Related Injury or Illness

Provide for Prompt Medical Care

If it’s an emergency, call 911 or direct the injured to an emergency room right away. For all other work-related injuries or illnesses, take or send the injured employee to a facility within the “Midwestern Insurance Alliance Select” Medical Provider Network (MPN), unless that employee had (prior to the injury) predesignated a physician. For more information about the MPN or the process for employees predesignating a physician, refer to the “Employee MPN Information” brochure or the “Time of Hire Pamphlet,” or contact MWIA Administrators at (800)-936-0384 or mpn@mwiainsurance.com for assistance.

Provide Documents to the Injured Employee

As required by law, within one working day of the injury, provide the injured employee with blank Workers Compensation Claims Form (DWC-1) and this “Employee MPN Information” brochure. Instruct the injured employee to complete and return the Workers Compensation Claims to you immediately. Then complete the employer section of the form. Retain the original, but provide the injured employee with a copy of the completed form.

Report the Claim to MWIA Administrators

Complete the Employer’s Report of Work-Related Injury or Illness (form 5020) and save a copy for your records. Do not delay submitting the Employer’s Report of Work-Related Injury or Illness if you have not received the completed Workers Compensation Claims form from the injured employee.

Workers Compensation Claims Form (DWC-1)

As required by law, provide this form to the injured employee within one working day of the injury and instruct the injured employee to complete and return it to you immediately. Then complete the employer section of the form and retain the original, but provide the injured employee with a copy.

Employer’s Report of Work-Related Injury or Illness

Complete this form and save a copy for your records. Then use the “Upload Tool” on this website to submit the completed form. Alternatively, you may mail the completed form to our corporate office at P.O. Box 436909, Louisville, KY 40253-6909 fax it to (502) 426-7067.

MPN Search Tools

A Medical Provider Network (MPN) is a group of health care providers used by your employer to treat workers injured on the job. Find health care providers in your area by using these MPN Search Tools.

MPN Employee Notification

This notification is required to be conspicuously posted at the employer’s place of business so all employees have access to it, and must be distributed to employees if they are injured at work.

Notice to Employees - Injuries Caused By Work

This notice advises employees of workers’ compensation benefits and must be posted in a conspicuous and easily accessible place, where employees and applicants can see it. If you need assistance in completing the fields in this form, contact (800)-936-0384 or mpn@mwiainsurance.com for assistance.

Time of Hire Pamphlet

California law requires employers to provide certain information relative to workers compensation to employees upon hire, for your convenience that is provided here. This document is available in both English and Spanish. Remember to also provide the MPN Employee Notification to employees upon hire.