Employer Requirements

As an employer, you are required by law to provide your employees notice about their workers’ compensation benefits, MPN providers, and where to seek treatment for workers’ compensation injuries. State Fund policyholders can use the materials below to meet those obligations. The chart below lists the mandated materials and when employers should distribute them.

Individual Form Links
You can view and download each individual form by clicking on the link(s) below.

Required Materials	Policy Inception	Time of Hire	Time of Injury
Notice to Employees English e13708 & Spanish e13709 Must be posted at every worksite in a location that is easily visible to your employees. Must be posted in both English and Spanish where there are Spanish-speaking employees.
Employee’s Guide to the State Fund Medical Provider Network e13176 Must be posted at every worksite in a location that is easily visible to your employees. Must also be provided to employee at time of injury or, where there is existing injury, and when transferring care into MPN.
MPN Implementation Notice e3841
New Employee’s Guide to Workers’ Compensation e13286
Workers’ Compensation Claim Form e3301 with instructions
Employer’s Report of Occupational Injury or Illness e3067 Must be completed and submitted to State Fund no later than 5 days from the date of knowledge of a work injury or illness.

PENALTIES
By law, you must post the Notice to Employees (State Fund form number 13708) in each of your business locations. Failure to post the required notice shall constitute a misdemeanor. In addition, any employer who fails to post the required notice could be assessed a civil penalty of up to seven thousand dollars ($7,000) for each violation.

Claims Kit
For your convenience, we’ve grouped the forms needed to report a claim into a single downloadable Claims Kit (PDF).

Call Us
If you have additional questions, please call our Customer Service Center at 888-STATEFUND (888-782-8338).