Employers will need to submit a workers' compensation packet. Supervisors/managers will need to complete the following:
Forward all forms to Risk Management within 4 days of department's date of knowledge to meet statutory timeline: sjcriskmgmt@sjgov.org
** time sensitive documents - see below for more information**
Within 24 hours of receiving notice or knowledge of injury/illness, which results in lost time beyond the date of injury or which results in medical treatment, the Manager/Supervisor must provide, in person, by mail or by email, a Employees Claim for Workers Compensation Benefits form (DWC1).
The injured worker must complete the employee section:
The Employer must complete the employer section:
The “Employer’s Report of Occupational Injury/Illness” (5020) form must be completed and forwarded to Risk Management within 4 working days of employer’s knowledge date to allow time for processing.
San Joaquin County’s Third-Party Administrator (TPA), reviews and determines the compensability on claims. The TPA will have a period of time in which to accept, deny or delay a claim. This period of time is the “determination period”. The injured worker may elect to use their leave accruals during this period. The injured worker must complete a “Notice of Leave of Absence for Temporary Disability Indemnity Payment” (Form 29). If the injured worker is not available to complete this form, please mail or email to the injured worker for completion.
Worker’s Compensation Leave runs concurrently with Family Medical Leave Act (FMLA). For information on FMLA, see “Request for Leave of Absence form. (RLOA)
Temporary Disability Payments (TD) will begin if the workers’ compensation claim is approved by the TPA. Risk Management will coordinate the disbursement of the TD payments. Amounts are calculated by the TPA and based on the employee’s average weekly wage. Please note that claims which involve lost time from work require a three-day waiting period before the start of TD payments. If an injured worker is off work 7 days or more requires immediate hospitalization this waiting period will be waived.
It is the injured worker’s responsibility to provide Manager/Supervisor any and all medical documentation for the workers’ compensation claim. Documents should include and are not limited to doctor’s first reports, work status reports, leave from work and work restriction notes. Provide Risk Management a copy of all documents received. Failure to submit doctor’s note may cause delay in Temporary Disability (TD) benefits to the injured worker.