For employers: updated forms for new state-mandated regulations

Important changes mandated by the California Division of Workers’ Compensation (DWC) will affect several workers’ compensation forms that you, as an employer, must provide to your employees. The changes went into effect on October 8, 2010.

To help you with these new requirements, State Fund is providing direct links to the forms below.

Please look for your scenario below, click on the links to the forms you need, print out the appropriate forms, and follow the instructions for posting and distribution.

All employers:

The forms below must be posted in close proximity to each other, in a conspicuous location frequented by employees.

• Notice to Employees posting notice [e13708]
• Notice to Employees posting notice Spanish [e13709]
  • This form must be posted if you have Spanish-speaking employees.
• Employee’s Guide to the State Fund Medical Provider Network (MPN) [e13176]

For employers to give to new employees at the time of hire:

• MPN Implementation Notice [e3841] 
• This is a new form that you may distribute to employees electronically if they have regular access to e-mail at work. 
• New Employee’s Guide To Workers’ Compensation [e13286]

For employers that are new to State Fund as of 10/8/2010, employers must give to all employees:

• MPN Implementation Notice [e3841]
  • This is a new form that you may distribute to employees electronically if they have regular access to e-mail at work. 

For employers to give to employees at time of injury:

• DWC-1 Claim form [e3301]
• Employee’s Guide to the State Fund Medical Provider Network (MPN) [e13176]

For employers with multiple locations, employers must post at each location:

• Notice to Employees posting notice [e13708]
• Notice to Employees posting notice Spanish [e13709]
  • This form must be posted if you have Spanish-speaking employees.
• Employee’s Guide to the State Fund Medical Provider Network (MPN) [e13176]

It is important that employers follow these notification mandates. Failure to provide the required forms to employees may result in fines of up to $7,000 as well as the loss of medical control of workplace claims.

If you have any questions about these notification requirements, please call the State Fund Customer Service Center at (877) 405-4545.