2648 E. Workman Ave., #223
Need to Report a California Workers Compensation Insurance Claim?
We’re here to help. Please access the appropriate forms below.
Once you have completed your forms, please:
- Fax them to Republic Capital at 626-332-8033, or
- Scan and email forms to: firstname.lastname@example.org
- If you need additional assistance, you may call 1 -888-423- 4228 ext. 108
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.
Employee: Complete the “Employee” section and give the form to your employer. Keep a copy and mark it “Employee’s Temporary Receipt” until you receive the signed and dated copy from your employer. You may call the Division of Workers’ Compensation and hear recorded information at (800) 736-7401. An explanation of workers’ compensation benefits is included as the cover sheet of this form. You should also have received a pamphlet from your employer describing workers’ compensation benefits and the procedures to obtain them.