Salinas California Form 5020 2025

Salinas California Form 5020: What You Should Know

Report of Loss of Use of Limbs (Form 5037B). NOTE: If, after completing this check list, the form does not appear on the list, return to Form 5020 in question. Attach a copy of Form 5020 to the Form DWC-1 in question. • Re-apply any forms that have been lost or destroyed, if applicable. • Complete the Application for Re-application of Worker's Compensation for the Employer, (WA-5030) (for Worker Comp to Reapply). • Re-apply any forms that have been lost or destroyed, if applicable. • DWC-1 Claim Check Sheet. The first report must be completed within 60 days of the date the employer was injured by another employee of the same employer. If any information is missing on the DWC-1 Claim Check Sheet, you must sign and date the entire application form and send it by certified mail. • Note: If the form is lost, destroyed or stolen, this form is not required.  • If the form is lost, destroyed or stolen, the DWC-1 Report must also be signed by the employee's doctor to allow the claim to be submitted (with no doctor signature.) • All other questions should be answered with “Y”. The purpose of this form is to protect the safety of the insured's life, health, physical condition and employment, as well as the financial assets and future of the insurance carrier which has incurred the loss and incurred the medical expense. • This form is NOT an admission of fault or justification for the insured's negligence. • If an employee is injured while conducting the employee's duties, no report will be required unless the employer is required to report to the DWC by rule. For questions about the contents of the report, contact the office above or call. Required documentation is required on all forms. It must be submitted as part of the DWC-1 report that is mailed by the insurance carrier, except as noted below. CCSM/USES Claim Check SUMMARY: It requires the reporting of an injured employee to the Workers' Compensation department. The report is used for insurance purposes to determine whether the injured employee should receive payment through Workers' Compensation.

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