Form 5020 ND 2025

Form 5020 ND: What You Should Know

June 2002) Form 5021  Insurers and self-insured employers of an employer who is not self-funded and whose workers' comp payments are not covered by a medical insurance plan shall provide the form to the injured or ill employee who is at the time of the accident or injury. IMPORTANT NOTE: The employer's report does not establish an estimate of an amount in damages due to illness, nor does it establish that the injury occurred as a result of an act of God. It merely confirms that the employee was at the time of the accident or injury. IMPORTANT NOTE: The employer's report of the accident or illness must be filed in duplicate, on or before the next pay period, if practicable. The other report form must be filed for each day that the employee remains at work. The employee may be entitled to damages for loss of wages during time of injury; however, if the employee can show that the injury was caused by an accident, or by willful and wanton misconduct, the person who is presumed to be the injured party must be awarded damages. The claim form may be used by the employer to: Provide compensation for expenses connected with the injury. Make an application for workers' compensation coverage or for a medical reimbursement. Process an application for benefits for a permanent or temporary impairment of the employee's ability to work. File an extension for an injury to an employee's ability to work. File a petition to dismiss a claim.  Claim Form (DWC 1) to the Personnel form 5021 — fill out all sections except “Claim for Benefits,” which is only required for a temporary impairment to an essential life function. Fill the Claim Report, including a statement of any benefits, if any, under the law. Process an Application for Workers' Compensation Coverage, or to make a Claim for the benefits of Workers' Compensation, if this will be necessary; but the form does not provide for an application for benefits if there has not been a claim made. The claim form is filed in duplicate, on or before the next pay period, if practicable.

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