Workers Compensation Claims Kit
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 firstname.lastname@example.org 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.
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.