Injuries on the Job

What, Why, Claim form, Worker's Compensation Pages - Back to main safety page

What to do when an injury occurs on the job:

1. If it is a major injury, call 911 immediately and render first aid.
2. Get emergency medical aid, render assistance and first aid
3. Notify your supervisor > employer > medic
4. Fill out the claim form your employer must provide after learning about your injury or illness

(This may be the state form or the employer's form that contains all the data found on the state form)
5. Get good medical care.

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Why fill out an Employee's Claim for Worker's Compensation Benefits?

1. A claim must be filed for you to be elligible for benefits
2. Even an injury that does not require medical assistance should be reported. If you do not seek medical assistance, the claim will be filed as an incident. If you later need medical assistance, the incident will be changed to an injury and you will be eligible for benefits. ( examples; a cut that later becomes infected, a sprain that does not heal )
NOTE: If no claim was filed at the time of the incident / accident, you will not be eligible for benefits if you need medical assistance at a later time.

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The claim form is a four (4) part form.

The back page is your temporary receipt.
The front page is the employer's copy (original).
Page two (2) is the employee's copy.
Page three (3) goes to the insurer or claims adjuster.
The temporary receipt may not contain all the employer information, but it is proof that you filed a claim on the date shown on your receipt. Once the claim form reaches the employer, they must complete the form and return your copy to you within one day. You means the employee, dependent, or reperesentative who filed the claim.

You may print four (4) copies of face of this form [page one], and one (1) copy of the back page [page two] (instructions) and create your own accident report packet

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Department of Industrial Relations;

Worker's Compensation homepage;
Fact sheet #1- what every worker should know
Fact sheet #2 - after you get hurt on the job
Fact sheet # 3a - temporary disability benefits
Fact sheet #3b - permanent diability benefits
Fact sheet #3c - working after a job injury
Fact sheet #4 - for more information
On line video link on this page to see the DIR videos on worker's compensation.
Worker's compensation system description
Information & Assistance Employee Guides
State Disability Insurance information ( SDI )
CAL / OSHA publications
How to use the State of California's phone system
Unemployment information
Unemployment frequently asked questions

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