Smart Form 5020

State of California
EMPLOYER'S REPORT OF
OCCUPATIONAL INJURY OR ILLNESS

Please complete in triplicate (type if possible) Mail two copies to:

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.

Employer

1. Firm Name *	1a. Policy Number

2. Mailing Address
Address *


City *	State *	Zip *

2a. Phone Number *

3. Location ( If different from mailing address	3a. Location Code

4. Nature of Business *	5. State unemployment insurance acct. no *

6. Type of Employer *

Private

State

County

City

School District

Other Gov't. Specify:

Injury or Illness

7. DATE OF INJURY / ONSET OF ILLNESS (mm/dd/yy) *	8. TIME INJURY/ILLNESS OCCURRED *	9. TIME EMPLOYEE BEGAN WORK *	10. IF EMPLOYEED DIED, DATE OF DEATH (mm/dd/yy)

11. UNABLE TO WORK FOR AT LEAST ONE FULL DAY AFTER DATE OF INJURY? *	12. DATE LAST WORKED (mm/dd/yy) *	13. DATE RETURNED TO WORK (mm/dd/yy)	14. IF STILL OFF WORK, Check box:
Yes No
15. PAID FULL DAYS WAGES FOR DATE OF INJURY OR LAST DAY WORKED? *	16. SALARY BEING CONTINUED? *	17. DATE OF EMPLOYER'S KNOWLEDGE/NOTICE OF INJURY/ILLNESS (mm/dd/yy) *	18. DATE EMPLOYEE WAS PROVIDED CLAIM FORM (mm/dd/yy) *
Yes No	Yes No

19. SPECIFIC INJURY/ILLNESS AND PART OF BODY AFFECTED, MEDICAL DIAGNOSIS *

20. LOCATION WHERE EVENT OR EXPOSURE OCCURRED (Number, Street, City, Zip) *

20a. COUNTY *

21. ON EMPLOYER'S PREMISES? *

Address *

City *	State *	Zip *

Yes

22. DEPARTMENT WHERE EVENT OR EXPOSURE OCCURRED (Number, Street, City, Zip) *	23. Other workers injured or ill in this event? *
	Yes No

24. EQUIPMENT, MATERIALS AND CHEMICALS THE EMPLOYEE WAS USING WHEN EVENT OR EXPOSURE OCCURRED *

25. SPECIFY ACTIVITY THE EMPLOYEE WAS PERFORMING WHEN EVENT OR EXPOSURE OCCURRED *

26. HOW INJURY/ILLNESS OCCURRED. DESCRIBE SEQUENCE OF EVENTS. SPECIFY OBJECT OR EXPOSURE WHICH DIRECTLY PRODUCEDTHE INJURY/ILLNESS *

27. Name and Address of Physician *

27a. Phone Number *

28. Hospitalized as an inpatient overnight?

28a. Phone Number

NO YES
(If yes then, name and address of hospital (number, street, city, zip)

Address

City	State	Zip

29. Employee treated at 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 CRT 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*.

Employee

30. EMPLOYEE NAME *	31. SOCIAL SECURITY NUMBER *	32. DATE OF BIRTH (mm/dd/yy) *

33. HOME ADDRESS (Number, Street, City, Zip) *

33a. PHONE NUMBER *

Address *

City *	State *	Zip *

34. SEX *	35. OCCUPATION (Regular job title,NO initials, abbreviations or numbers) *	36. DATE OF HIRE (mm/dd/yy) *
Male Female

37. Employee Usually Works *
	Hours per day.
	Days per week.
	total weekly hours

37a. Emplyee Status *
	Regular, Full-time
	Part-time
	Temporary
	Seasonal

37b. UNDER WHAT CLASS CODE OF YOUR POLICY WHERE WAGES ASSIGNED

38. GROSS WAGES/SALARY *	39. OTHER PAYMENTS NOT REPORTED AS WAGES/SALARY (e.g. tips, meals, overtime, bonuses, etc.)? *
$ per	Yes No

Completed By (type or print) *

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