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California Workers Compensation Forms

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The California Department of Insurance administers workers compensation insurance in the state.  We have provided most workers comp forms for employers and employees that are commonly required in CA.. 

We have also included helpful guides and resources to help educate employers about work comp coverage, claims, and the CA Experience Rating Plan.  For additional forms please contact one of our Workers Comp Specialists at 888-611-7467.

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CA Workers Comp Information

Questions? Call 888.611.7467 for a Workers Compensation Shop Specialist

 

 CA Comp Forms

 

California Workers Compensation Forms

CA Acord 130 Workers Compensation Application

The standard Acord 130 application form for workers comp coverage in California.

California Employer Fact Sheet for Employers

Information for Employers about Workers Compensation in CA and the Division of Workers' Compensation Insurance.

California Application for Exclusion of Officers and Stockholders

Owners and Officers of corporations should complete this form to exclude themselves from a work comp policy.

CA Affidavit of Exemption for Workers' Compensation Insurance

Exemption form for California Contractors State Licensing Board.  Contractors must file proof of coverage and complete the exemption form if they are exempt from work comp coverage.

CA First Report of Injury Form

This form allows employers to report an injury or illness to their carrier and or the CA Department of Insurance. 

Employee Claim Form for Potential Eligibility for Coverage

California Employees may use this form to report a claim to the State in order to determine eligibility for coverage.

CA Doctors First Report of Injury or Illness

Doctors should use this form to report injury and illness treatment to the insurance company and the employer.

California Drug-Free Workplace Certification Form

California provides for certain credits associated with drug free workplaces.  This form is the required certification for Employers.

California Guide for Injured Workers

The official employee guide for injured workers in California.

CA Notification of Change in Ownership or Combinability- Form 601

This Form must be filed with your insurance carrier in the event their is a change in ownership or when two entities should be combined on a single policy due to common ownership.

CA Request for Accommodations for Disabilities

California employees with disabilities should file this form with their employer in the event special work accommodations are needed.

California State Fund Guide to Experience Modifiers

An information guide for employers designed to explain California Experience Rating Plan.

CA State Resources

Division of Workers’ Compensation (DWC)

http://www.dir.ca.gov/dwc/

dwc_home_page.htm
1515 Clay Street, 17th Floor
Oakland, California 94612

(800) 736-7401, (510) 286-7100
Mailing Address:
Post Office Box 420603
San Francisco, California 94142

Division of Workers’ Compensation Medical Unit

http://www.dir.ca.gov/dwc/

MedicalUnit/imchp.html
1515 Clay Street, 18th Floor
Oakland, California 94612

(800) 794-6900 (in California), (510) 286-3700, Complaint Line: (800) 999-1041

Mailing Address:
Post Office Box 71010
San Francisco, California 94142

Workers’ Compensation Appeals Board (WCAB)

http://www.dir.ca.gov/WCAB/
455 Golden Gate Avenue, Suite 9328
San Francisco, California 94102-3660

(800) 736-7401, (415) 703-5020 

Mailing Address:
Post Office Box 429459
San Francisco, California 94142-9459
Self-Insurance Plans (SIP)—http://www.dir.ca.gov/SIP/
2265 Watt Avenue, Suite 1
Sacramento, California 95825
(916) 483-3392, Fax: (916) 483-1535

State Compensation Insurance Fund (SCIF)

http://www.scif.com/
1275 Market Street
San Francisco, California 94103
(415) 565-1234,

Claims Reporting Service: (888) 222-3211

Fraud Hotline: (888) 786-7372

 

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