Form 5020 for Palmdale California 2025

Form 5020 for Palmdale California: What You Should Know

Employer Death — June 2025 (page 31 of 109). The form must be filed within one year after the date of the employee's death. (Example: Employees must file this form by December 1, 2014, if they have died within the past year.) If you have a relative who is not authorized to handle worker's comp claims, you can sign the form on your behalf. DO NOT FILE THIS FORM WITH THE EXAMINER DUE TO THE POTENTIAL HANDLING HAZARD.  To file a claim with the office of the Department of Industrial Relations or the Division of Workers' Compensation,  you must complete the above-listed forms and mail to the correct address listed below. If you wish to make and receive a claim online, please visit: (This form may not be used for online processing.) Note: You are required to fill out this form in the following ways: Type the word “Claim” into the appropriate box, including the space to insert the name(s) of the employee(s) for whom the claim is filed, if applicable. Enter any information, including income and date(s) of employment, not on this form, such as your employer's name, address, or contact information. Note: If you use this claim form to file a claim for employee welfare benefits (wage replacement for death or severe physical impairment), you are not required to use this form to file a claim with the city of Palmdale's office. DWC-1 — Workers' Compensation Claim Sheet — June 2014 Worker's Compensation Note: If you have not completed all the pages of the form, or the completed form is illegible, please contact the Division of Workers' Compensation at the address listed below. You must provide a signed statement. Complete this claim form carefully and have a copy for your records. Failure to complete this claim form before the date of death/injury may prevent payment of worker's compensation benefits.

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