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Notice To Employees-Injuries Caused By Work DWC 7 - California

Notice To Employees-Injuries Caused By Work Form. This is a California form and can be used in General Workers Comp .
 Fillable pdf Last Modified 9/27/2010
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STATE OF CALIFORNIA - DEPARTMENT OF INDUSTRIAL RELATIONS Division of Workers' Compensation Notice to Employees--Injuries Caused By Work You may be entitled to workers' compensation benefits if you are injured or become ill because of your job. Workers' compensation covers most work-related physical or mental injuries and illnesses. An injury or illness can be caused by one event (such as hurting your back in a fall) or by repeated exposures (such as hurting your wrist from doing the same motion over and over). Benefits. Workers' compensation benefits include: · Medical Care: Doctor visits, hospital services, physical therapy, lab tests, x-rays, and medicines that are reasonably necessary to treat your injury. You should never see a bill. For injuries occurring on or after 1/1/04, there is a limit on some medical services. Temporary Disability (TD) Benefits: Payments if you lose wages while recovering. Permanent Disability (PD) Benefits: Payments if your injury causes a permanent disability. Vocational Rehabilitation: Services and payments if your injury prevents you from returning to your usual job or occupation. This benefit applies to injuries that occurred prior to 1/1/04. Supplemental Job Displacement Benefit: A nontransferable voucher payable to a state approved school if you are injured on or after 1/1/04, the injury results in a permanent disability, you don't return to work within 60 days after TD ends, and your employer does not offer modified or alternative work. Death Benefits: Paid to dependents of a worker who dies from a work-related injury or illness. · · · · · Naming Your Own Physician Before Injury. You may be able to choose the doctor who will treat you for a job injury or illness during the first 30 days after the injury . If eligible, you must tell your employer, in writing, the name and address of your personal physician before you are injured. For instructions, see the written information about workers' compensation that your employer is now required to give to new employees. If You Get Hurt: 1. Get Medical Care. If you need first aid, contact your employer. If you need emergency care, call for help immediately. Emergency phone numbers: Ambulance Doctor _______________ Fire Dept. _______________ Hospital _______________ Police _______________ _____________ 2. Report Your Injury. Report the injury immediately to your supervisor or to: Employer representative ______________ phone number ____________. Don't delay. There are time limits. If you wait too long, you may lose your right to benefits. Your employer is required to provide you a claim form within one working day after learning about your injury. Within one working day after an employee files a claim form, the employer shall authorize the provision of all treatment, consistent with the applicable treating guidelines, for the alleged injury and shall continue to provide treatment until the date that liability for the claim is accepted or rejected. Until the date the claim is accepted or rejected, liability for medical treatment shall be limited to ten thousand dollars ($10,000). 3. See Your Primary Treating Physician (PTP). This is the doctor with overall responsibility for treating your injury or illness. If you named your personal physician before injury (see above), you may see him or her for treatment in certain circumstances. Otherwise, your employer has the right to select the physician who will treat you for the first 30 days. You may be able to switch to a doctor of your choice after 30 days. Special rules apply if your employer offers a Health Care Organization (HCO) or after 1/1/05, has a medical provider network. Contact your employer for more information. Discrimination: It is illegal for your employer to punish or fire you for having a work injury or illness, for filing a claim, or testifying in another person's workers' compensation case. If proven, you may receive lost wages, job reinstatement, increased benefits, and costs and expenses up to limits set by the state. Questions? Learn more about workers' compensation by reading the information that your employer is required to give you at time of hire. If you have questions, see your employer or the claims administrator (who handles workers' compensation claims for your employer): Claims Administrator _____________________________________ Address __________________________ City ________________ State ____ Zip _______ Phone __________________________ Policy Expiration Date ___________________________ The employer is insured for workers' compensation by _____________________________ (Enter "self-insured" if appropriate) If the workers' compensation policy has expired, contact a Labor Commissioner at the Division of Labor Standards Enforcement - their number can be found in your local White Pages under California State Government, Department of Industrial Relations. You can get free information from a State Division of Workers' Compensation Information & Assistance Officer. The nearest Information & Assistance Officer is at: Address ______________________ City ______________ Phone _________________ Hear recorded information and a list of local offices by calling toll-free (800) 736-7401. Learn more online: www.dir.ca.gov. False claims and false denials. 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 and may be fined and imprisoned. Your employer may not be liable for the payment of workers' compensation benefits for any injury that arises from your voluntary participation in any off-duty, recreational, social, or athletic activity that is not part of your work-related duties. DWC 7 (8/1/04) American LegalNet, Inc. www.USCourtForms.com ESTADO DE CALIFORNIA - DEPARTAMENTO DE RELACIONES INDUSTRIALES Division De Compensación Al Trabajador Aviso a los Empleados--Lesiones Causadas por el Trabajo Es posible que usted tenga derecho a beneficios de compensación para trabajadores, si usted se lesiona o se enferma a causa de su trabajo. La compensación para trabajadores cubre la mayoría de las lesiones y enfermedades físicas o mentales relacionadas con el trabajo. Una lesión o enfermedad puede ser causada por un evento (como por ejemplo el lastimarse la espalda en una caída) o por acciones repetidas (como por ejemplo lastimarse la muñeca por hacer el mismo movimiento una y ot
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