How do you file a claim?

SUPERVISORS to report a new injury, call the Injury Intake Center at (888) 826-7835 and complete the (click) New Injury Packet. If the employee declines treatment, complete the steps below.

DECLINATION OF TREATMENT if the employee does not wish to seek treatment at this time, complete the (click) Declination Packet and send a copy to the Workers' Compensation Division, maintain a copy for your records and provide a copy to the employee. If your department policy requires the injury be reported to the Injury Intake Center please advise the intake person the injury is a Record Only.

REQUEST FOR TREATMENT FOLLOWING A DECLINATION OF TREATMENT If the employee later requests to seek medical treatment, provide the employee with the Employee Claim Form (DWC-1) within 24 hours, either personally or via First Class Mail. If not previously reported, report the injury or illness into the Injury Intake Center at (888) 826-7835 and complete the remainder of the required forms listed at the top of the Supervisor Injury Check List.

AUTO ACCIDENTS Please note, employees injured while DRIVING as part of the Ride Share Program or while driving while engaging in County business, in a personal or County vehicle, should be offered medical treatment and . The claims adjuster will review Please also complete the County of Riverside Confidential Vehicle Accidents/Incidents Report (Safety Form 942.6) and send to Safety as well as the Workers' Compensation Department.

EMPLOYEES report the injury or illness to your Supervisor or Manager immediately. Make sure your supervisor or someone else in management knows as soon as possible. If your injury or illness developed gradually (like tendinitis or hearing loss), report it as soon as you learn or believe it was caused by your job. Reporting promptly helps avoid problems and delays in receiving benefits, including medical care. If the County of Riverside does not learn about your injury within 30 days, you could lose your right to receive Workers’ Compensation benefits.

FOR SERIOUS INJURIES OR DEATH IMMEDIATELY DIAL 911
NOTIFY SAFETY AT (951) 955-3520 OR AFTER HOURS (951) 313-9589
CONTACT THE WORKERS' COMPENSATION DIVISION AT (951) 955-3530 OR (951) 955-5864

SERIOUS INJURIES MAY INCLUDE, BUT ARE NOT LIMITED TO: Threat to life or limb; need for immediate surgery; amputations; loss of consciousness; severe burns; hospitalization in excess of 24 hours, for more than observation.

Forms

INJURY CHECK LIST A detailed document checklist that will ensure you do not miss a step in properly filing a Workers' Compensation Claim.

FACTS FOR INJURED WORKERS This provides a brief overview of the benefits provided through the Workers’ Compensation system. It also explains other programs unique to the County of Riverside and County of Riverside employees.

EMERGENCY SITUATIONS Procedures designed to assist a supervisor through emergency situations.

MEDICAL SERVICE ORDER This form should ALWAYS be sent with the injured worker when they are being sent for treatment to an industrial clinic. This form is required in triplicate. Please call the Workers' Compensation Division for a supply [951-955-5864].

DECLINATION OF TREATMENT STATEMENT [WC5a] Complete this form if the injured worker does not wish to seek treatment at this time. You may provide a DWC-1 to the employee as well; however, it should not be completed and returned unless the injured worker requests to seek treatment. NOTE: IF THE INJURED WORKER LATER REQUESTS TO SEEK TREATMENT A DWC-1 MUST BE PROVIDED WITHIN 24 HOURS OF REQUEST.

ACKNOWLEDGEMENT FORM [WC35] This form is given to an injured worker for him or her to acknowledge receipt of the Employee Claim Form DWC-1, Facts for Injured Workers', Medical Service Order, Temporary Prescription Card, Notice of the Medical Provider Network (MPN).

SUPERVISOR'S REPORT OF EMPLOYEE INJURY [SAFETY FORM 674]: This is a safety form that can be obtained directly from the Human Resources, Safety Web Site. How do I fill out the Supervisor's Report of Employee Injury?

EMPLOYERS FIRST REPORT [FORM 5020] Report the injury or illness to the Injury Intake Center at (888) 826-7835 to have the form completed. If the injury or illness was not reported to the Injury Intake Center, then this form must be completed. This Form SHOULD NEVER BE FILLED OUT BY HAND. It is a CONFIDENTIAL Form. This means only the Supervisor/Manager (via the Call Intake Center) and the Workers' Compensation Division should have access to this form.

EMPLOYEE CLAIM FORM [DWC-1] This form should be provided to an employee when the injury is reported, or within 24 hours of when the injury is reported. This form is a multi-copy form. PLEASE make every attempt to utilize the pre-printed form. If you need copies of this form call the Workers' Compensation Division. If you must use the web form, please note the multi-copy requirements and how they must be distributed.

EMPLOYEE ACKNOWLEDGEMENT OF THE MEDICAL PROVIDER NETWORK [MPN] this form also includes information on how to access the MPN. To access the MPN website click here.

AUTO ACCIDENTS Please note, employees injured while DRIVING as part of the Ride Share Program or while driving while engaging in County business, in a personal or County vehicle, should be offered medical treatment and . The claims adjuster will review Please also complete the County of Riverside Confidential Vehicle Accidents/Incidents Report (Safety Form 942.6) and send to Safety as well as the Workers' Compensation Department.

GUIDEBOOK FOR INJURED WORKERS This is the State's Guidebook to help injured workers understand the status of their workers' compensation benefits and what actions are being taken on their workers' compensation claim.

RETURN-TO-WORK REFERRAL FORM The County of Riverside is committed to returning employees to work as soon as possible. For this reason we have created the Return to Work program to coordinate physician opinions with employment/work opportunities. If the physician finds the employee can return to work in a modified or alternate capacity, please fill out this form and send it to the Return to Work Coordinator in the Workers’ Compensation Division.