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The California Department of Insurance administers workers compensation insurance in the state. We have provided the most common workers compensation forms for employers and employees that are commonly utilized in California. We make every effort to keep our forms library updated with the most current versions of our California Workers' Comp Forms.
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 and help please contact one of our Workers Comp Specialists at 888-611-7467.
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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.
Each state has its own laws and requirements regarding when and how employers are allowed to opt-out of coverage under their workers compensation policy. Some states make it easier than others because they don't require anything to be filed. Other states require special inclusion or exclusion affidavit documentation. Failure to comply often causes employers to have to pay premium on themselves even when they wanted to be excluded form coverage.
A waiver of subrogation means that a business and their insurance company is foregoing all rights to file suit, or seek damages, from another business. This is common in the construction industry as builders attempt to protect their company from negligence. A workers' comp waiver of subrogation does not prevent an injured employee from filing a lawsuit for damages. This coverage typically add about $100 to the cost of a work comp policy.
A Certificate of Insurance is a document that serves as evidence of insurance or proof of coverage. Certificates indicate your current coverages and policy limits. Insurance Agencies issue on an insured's behalf and they often list a third party as a certificate holder. This means they should be notified if a policy cancels prior to expiration. Requests for any special wording should be carefully checked against the policy language before being added to a certificate as they can create legal issues with coverage.
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State Resources for California
California Department of Insurance
Consumer Communications BureauLos Angeles, CA 90013213-897-8921 800-927-4357
CA Division of Workers Compensation
Post Office Box 420603 San Francisco, California 94142 415-703-4600 DWC Home Page
State Compensation Insurance Fund (SCIF)
1275 Market StreetSan Francisco, CA 94103 415-565-1234 California State Fund
Workers' Compensation Insurance Rating Bureau of California
525 Market Street, Ste. 800San Francisco, CA 94105-2716415-777-0777 WCIRB
Workers’ Compensation Appeals Board (WCAB)
455 Golden Gate Avenue, Suite 9328San Francisco, California 94102-3660800-736-7401 California Appeals Board
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