Fill and Sign the Form 5020 Fill Online Printable Fillable Blankpdffiller

State of California Please complete in triplicate (type if possible) Mail two copies to: EMPLOYER'S REPORT OF OCCUPATIONAL INJURY OR ILLNESS 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 subsequentl\ y 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 ser\ ious injury, illness, or death must be reported immediately by telephone or telegraph to the nearest office of the California Divis\ ion of Occupational Safety and Health. E M P L O Y E R 6. TYPE OF EMPLOYER: City School District Private \ County State Other Gov't, Specify: 17. DATE OF EMPLOYER'S KNOWLEDGE /NOTICE OFINJURY/ILLNESS (mm/dd/yy) 18. DATE EMPLOYEE WAS PROVIDED CLAIM FORM 15. PAID FULL DAYS WAGES FOR DATE OF SEX 16. SALARY BEING CONTINUED? NJURY OR LAST FORM (mm/dd/yy) Yes No DAY WORKED? Yes No 19. SPECIFIC INJURY/ILLNESS AND PART OF BODY AFFECTED, MEDICAL DIAGNOSIS\ if available, e.g.. Second degree burns on right arm, tendonitis on left elbow, lead poisoning AGE I N J U R Y 21. ON EMPLOYER'S PREMISES? 20a. COUNTY 20. LOCATION WHERE EVENT OR EXPOSURE OCCURRED (Number, Street, City, Zi\ p) Yes No 22. DEPARTMENT WHERE EVENT OR EXPOSURE OCCURRED, e.g.. Shipping departme\ nt, machine shop. 23. Other Workers injur\ ed or ill in this event? Yes No O R I L L N E S S PART OF BODY 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 possiblewhile the information is being used for occupational safety and health p\ urposes. See CCR 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*. E M P L O Y E E 35. OCCUPATION (Regular job title, NO initials, abbreviations or number\ s) 37b. UNDER WHAT CLASS CODE OF YOURPOLICY WHERE WAGES ASSIGNED 37a. EMPLOYMENT STATUS 37. EMPLOYEE USUALLY WORKS regular, full-time part-time EXTENT OF INJURY total weekly hours days per week, hours per day, temporary seasonal 39. OTHER PAYMENTS NOT REPORTED AS WAGESISALARY (e.g. tips, meals, over\ time, bonuses, etc.)? 38. GROSS WAGES/SALARY per $ \ Yes No Date (mm/dd/yy) Signature & Title Completed By (type or print) • Confidential information may be disclosed only to the employee, for\ mer employee, or their personal representative (CCR Title 8 14300.35),\ to others for the purpose of processing a workers' compensation or othe\ r insuranc e 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 provis\ ion 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 OSHA CASE NO. FATALITY 1. FIRM NAME Ia. Policy Number 2. MAILING ADDRESS: (Number, Street, City, Zip) \ 2a. Phone Number 3. LOCATION if different from Mailing Address (Number, Street, City and\ Zip) \ 3a. Location Code 4. NATURE OF BUSINESS; e.g.. Painting contractor, wholesale grocer, sawm\ ill, hotel, etc. 5. State unemployment insurance acct.no Please do not use this column CASE NUMBER OWNERSHIP INDUSTRY OCCUPATION 7. DATE OF INJURY / ONSET OF ILLNESS(mm/dd/yy) 8. TIME INJURY/ILLNESS OCCURRED PM AM 9. TIME EMPLOYEE BEGAN WORK PM AM 1 0. IF EMPLOYEE DIED, DATE OF DEATH (mm/dd/yy) 1 1. UNABLE TO WORK FOR AT LEAST ONEFULL DAY AFTER DATE OF INJURY? Yes No 12. DATE LAST WORKED (mm/dd/yy) 13. DATE RETURNED TO WORK (mm/dd/yy) 14. IF STILL OFF WORK, CHECK THIS BOX: DAILY HOURS DAYS PER WEEK WEEKLY HOURS WEEKLY WAGE COUNTY NATURE OF INJURY 24. EQUIPMENT, MATERIALS AND CHEMICALS THE EMPLOYEE WAS USING WHEN EVENT\ OR EXPOSURE OCCURRED, e.g.. Acetylene, welding torch, farm tractor, sca\ ffold 25. SPECIFIC ACTIVITY THE EMPLOYEE WAS PERFORMING WHEN EVENT OR EXPOSURE\ OCCURRED, e.g.. Welding seams of metal forms, loading boxes onto truck.\ 26. HOW INJURY/ILLNESS OCCURRED. DESCRIBE SEQUENCE OF EVENTS. SPECIFY OBJECT OR EXPOSUR\ E WHICH DIRECTLY PRODUCED THE INJURYIILLNESS, e.g.. Worker stepped back \ to inspect work and slipped on scrap material. As he fell, he brushed against fresh weld, and burned right ha\ nd. USE SEPARATE SHEET IF NECESSARY SOURCE EVENT SECONDARY SOURCE