Visit the links below for workplace safety and workers compensation forms. For any questions, contact our HR department at (818) 546-8415.
Unfortunately, injuries do happen on the job. If you or an employee gets injured, you must complete both of the forms listed below:
Reporting Work Related Accidents, Injuries, or Occupational Illnesses
All accidents, injuries, or work-related occupational illnesses should be reported to the employee's supervisor immediately or within twenty-four (24) hours from the time of occurrence.
The injured employee should receive the California Workers Compensation Claim Notice (Form DWC 1), complete the required information, and return it to the employee's supervisor. The employer is then required to complete the employer's portion of the DWC 1 form and submit notice of the claim within one (1) working day after its receipt from the injured employee to Sedgwick, the workers' compensation plan claim administrator and provide a copy of the completed form to the injured employee or their representative.
Reporting CA Workers Compensation Claim Notices (DWC 1) to Sedgwick
Reporting a workers' compensation claim to Sedgwick's claim intake office can be done using the following methods:
Email Intake: Email the completed DWC 1 to SCMSNIC@SedgwickCMS.com. (Only use the last 4 numbers of the employees' social security number when reporting).
FAX Intake: Send To: (866) 261-5795 and fax the completed DWC 1 form
Phone Intake: Call (855) 572-5966 and report the required DWC 1 information
A copy of the completed DWC 1 form needs to also be sent to the SCC Human Resources Department via fax at (818) 546-8475.
Employer’s Report of Occupational Injury or Illness — CA Form 5020
The supervisor should complete CA form 5020 to provide information about workplace accidents or occupational illnesses. This form must be submitted to Sedgwick no later than five (5) days after the employer received notice of the incident so the claim can be adjudicated.
Cal-OSHA Required Notification of Serious Injuries or Work-related Deaths
The supervisor is required by law to immediately report to Cal-OSHA any workplace accident resulting in a worker's death or serious bodily injury/illness. Reporting the accident to the workers' compensation claims administrator – DOES NOT meet the employer's duty to report these accidents to Cal-OSHA. All supervisors and managers shall immediately report critical incidents/accidents to the employer's human resources or risk management department. Should there be an incident that occurs after hours, you must also report the incident to Deanna Simeone, Director of Human Resources, at (626) 221-6772.
Supervisors must report work-related or suspected work-related fatalities, catastrophes, and serious injuries or illnesses within eight (8) hours by phone or fax to the nearest district office of the Cal-OSHA Enforcement Unit in the Division of Occupational Safety & Health. A serious injury or illness is one that requires employee hospitalization for more than 24 hours for other than medical observation or in which a part of the body is lost (amputation or loss of an eye), or permanent disfigurement occurs. Work-related serious injury or illness does not include an accident on a public street or highway. To determine the contact information of the nearest CAL/OSHA Enforcement Office for reporting an incident visit: DWC office locations Telephone reports can be made 24 hours a day, 7 days a week.