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. 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 telegraph to the nearest office of the California Division of Occupational Safety and Health. 1a. Policy Number 2a. Phone Number 1. FIRM NAME E 2. MAILING ADDRESS: (Number, Street, City, Zip) M P L 3. LOCATION if different from Mailing Address (Number, Street, City and Zip) O Y 4. NATURE OF BUSINESS; e.g.. Painting contractor, wholesale grocer, sawmill, hotel, etc. E R 6. TYPE OF EMPLOYER: Private State County City School District Please do not use this Column CASE NUMBER 3a.Location Code OWNERSHIP 5. State unemployment insurance acct. no. Other Gov't, Specify: ___________________ 10. IF EMPLOYEE DIED, DATE OF DEATH (mm / dd / yy) INDUSTRY 7. DATE OF INJURY / ONSET OF ILLNESS ( mm / dd / yy) 11. UNABLE TO WORK FOR AT LEAST ONE FULL DAY AFTER DATE OF INJURY? Yes No 8. TIME INJURY/ILLNESS OCCURRED ____________ AM _____________ PM 12. DATE LAST WORKED (mm /dd / yy) 9. TIME EMPLOYEE BEGAN WORK ____________ AM _____________ PM OCCUPATION 13. DATE RETURNED TO WORK (mm / dd / yy) 14. IF STILL OFF WORK, CHECK THIS BOX: I 15. PAID FULL DAY'S WAGES FOR 16. SALARY BEING CONTINUED? 17. DATE OF EMPLOYER'S KNOWLEDGE 18. DATE EMPLOYEE WAS PROVIDED N DATE OF INJURY OR LAST /NOTICE OF INJURY/ILLNESS (mm / dd / yy) CLAIM FORM (mm / dd / yy) Yes No Yes No J DAY WORKED? U 19. SPECIFIC INJURY/ILLNESS AND PART OF BODY AFFECTED, MEDICAL DIAGNOSIS if available, e.g.. Second degree burns on right arm, tendonitis on left R elbow, lead poisoning Y 20. LOCATION WHERE EVENT OR EXPOSURE OCCURRED (Number, Street, City, Zip) 22. DEPARTMENT WHERE EVENT OR EXPOSURE OCCURRED, e.g.. Shipping department, machine 20a. COUNTY SEX AGE DAILY HOURS 21. ON EMPLOYER'S PREMISES? Yes No O shop. R 23. Other Workers Injured/Ill in this event? Yes No DAYS PER WEEK 24. EQUIPMENT, MATERIALS AND CHEMICALS THE EMPLOYEE WAS USING WHEN EVENT OR EXPOSURE OCCURRED, e.g.. Acetylene, welding torch, farm tractor, scaffold: WEEKLY HOURS I L L 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 N SEPARATE SHEET IF NECESSARY. E S S 27. NAME AND ADDRESS OF PHYSICIAN (Number, Street, City, Zip) 27a. Phone Number 25. SPECIFIC ACTIVITY THE EMPLOYEE WAS PERFORMING WHEN EVENT OR EXPOSURE OCCURRED, e.g.. Welding seams of metal forms, loading boxes onto truck WEEKLY WAGE COUNTY NATURE OF INJURY 28. HOSPITALIZED AS AN INPATIENT OVERNIGHT? City, Zip). No Yes If yes then, NAME AND ADDRESS OF HOSPITAL (Number, Street, 28a. Phone Number PART OF BODY 29. Employee treated in Emergency Room? Yes No 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.* 30. EMPLOYEE NAME 31. SOCIAL SECURITY NUMBER 32. DATE OF BIRTH (mm /dd / yy) SOURCE EVENT 33. HOME ADDRESS (Number, Street, City, Zip) 33a. PHONE NUMBER E M 34. SEX: P Male Female L O 37. EMPLOYEE USUALLY WORKS Y E ________ hours per day, ________ E 38. GROSS WAGES/SALARY 35. OCCUPATION ( Regular job title, NO initials, abbreviations or numbers) 36. DATE OF HIRE (mm / dd / yy) SECONDARY SOURCE 37a. EMPLOYMENT STATUS regular, full-time days per week, _________ total weekly hours temporary part-time seasonal 37b. UNDER WHAT CLASS CODE OF YOUR POLICY WERE WAGES ASSIGNED? EXTENT OF INJURY $ ____________ per _____________ Completed By (type or print) Signature & Title 39. OTHER PAYMENTS NOT REPORTED AS WAGES/SALARY (e.g. tips, meals, overtime, bonuses, etc.)? Yes No 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 American LegalNet, Inc. www.USCourtForms.com