State of California EMPLOYER’S REPORT OF OCCUPATIONAL INJURY OR ILLNESS	Please complete in triplicate (type if possible) Mail two copies to:	OSHA Case No.
ICW GROUP INSURANCE COMPANY OF THE WEST EXPLORER INSURANCE COMPANY	San Diego Office PO Box 509039 San Diego, CA 92150-9039 Toll Free (800) 877-1111 Direct (877) 442-9669 Fax (858) 436-8916
Fatality
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 telegram to the nearest office of the California Division of Occupational Safety and Health.
EMPLOYER	FIRM NAME	1a. Policy Number	Do not use this Column
MAILING ADDRESS (Number, Street, City, Zip)	2a. Phone Number	CASE NUMBER
LOCATION, If different from Mailing Address (Number, Street, City, Zip)	3a. Location Code	OWNERSHIP
NATURE OF BUSINESS e.g. Painting contractor, wholesale grocer, sawmill, hotel, etc.	State Unemployment Insurance acct. no.	INDUSTRY
TYPE OF EMPLOYER Private State County City School District Other Gov’t, Specify:	OCCUPATION
INJURY OR ILLNESS	7. DATE OF INJURY / ONSET OF ILLNESS (mm/dd/yy)	8. TIME INJURY/ILLNESS OCCURRED AM PM	9. TIME EMPLOYEE BEGAN WORK AM PM	10. IF EMPLOYEE DIED, DATE OF DEATH (mm/dd/yy)	SEX
11. UNABLE TO WORK FOR AT LEAST ONE FULL DAY AFTER DATE OF INJURY? YES NO	12. DATE LAST WORKED (mm/dd/yy)	13. DATE RETURNED TO WORK (mm/dd/yy)	14. IF STILL OFF WORK CHECK THIS BOX:	AGE
15. PAID FULL WAGES FOR DAY OF INJURY OR LAST DAY WORKED? YES NO	16. SALARY BEING CONTINUED? YES NO	17. DATE OF EMPLOYERS KNOWLEDGE/NOTICE OF INJURY/ILLNESS (mm/dd/yy)	18. DATE EMPLOEE WAS PROVIDED EMPLOYEE CLAIM FORM (mm/dd/yy)	DAILY HOURS
19. SPECIFIC INJURY/ILLNESS AND PART OF BODY AFFECTED, MEDICAL DIAGNOSIS, if available, e.g., Second degree burns on right arm, tendonitis of left elbow, lead poisoning	DAYS PER WEEK
20. LOCATION WHERE EVENT OR EXPOSURE OCCURRED (Number, Street, City, Zip)	20A. COUNTY	21. ON EMPLOYERS PREMISES? YES NO or	WEEKLY HOURS
22. DEPARTMENT WHERE EVENT OR EXPOSURE OCCURRED. e.g. Shipping department, machine shop	OTHER WORKERS INJURED/ILL IN THIS EVENT? YES NO	WEEKLY WAGE
24. EQUIPMENT, MATERIALS AND CHEMICALS THE EMPLOYEE WAS USING WHEN EVENT OR EXPOSURE OCCURRED. e.g. Acetylene, welding torch, farm tractor, scaffold:	COUNTY
25. SPECIFIC ACTIVITY THE EMPLOYEE WAS PERFORMING WHEN EVENT OR EXPOSURE OCCURRED. e.g. Welding seams of metal forms, loading boxes onto truck.	NATURE OF INJURY
26. HOW INJURY/ILLNESS OCCURRED. DESCRIBE SEQUENCE OF EVENTS. SPECIFY OBJECT OR EXPOSURE WHICH DIRECTLY PRODUCED THE INJURY/ILLNESS. e.g. Worker stepped back to inspect work and slipped on scrap material. As he fell, he brushed against fresh weld, and burned right hand. USE SEPARATE SHEET IF NECESSARY.	PART OF BODY
27. NAME AND ADDRESS OF PHYSICIAN (Number, Street, City, Zip)	27a. Phone Number	SOURCE
28. HOSPITALIZED AS AN INPATIENT OVERNIGHT? YES NO If yes, then, NAME AND ADDRESS OF HOSPITAL (Number, Street, City, Zip)	28a. Phone Number
29. Employee Treated in Emergency room? YES NO	EVENT
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 CCR 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)	SECONDARY SOURCE
33. HOME ADDRESS (Number, Street, City, Zip)	33a. PHONE NUMBER
34. SEX MALE FEMALE	35. OCCUPATION (Regular job title – NO initials, abbreviations or numbers)	36. DATE OF HIRE (mm/dd/yy)
37. EMPLOYEE USUALLY WORKS hours per day, days per week, total weekly hours	37a. EMPLOYMENT STATUS regular, full-time part-time temporary seasonal	37b. UNDER WHAT CLASS CODE OF YOUR POLICY WERE WAGES ASSIGNED?	EXTENT OF INJURY
38. GROSS WAGES/SALARY $ per	39. OTHER PAYMENTS NOT REPORTED AS WAGES/SALARY (e.g. tips, meals, overtime, bonuses, etc.)? YES NO
Completed By (type or print)	Signature, Title & Date	Date (mm/dd/yy)
* 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

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