<div class='html-Content' xmlns="https://www.w3.org/1999/xhtml"> <div class='head-Content'> <meta http-equiv="Content-Type" content="text/html; charset=UTF-8"> <title> Forms </title> <meta name="keywords" content="Forms"> <meta name="description" content="Forms"> <meta name="robots" content="noindex"> <link rel="stylesheet" type="text/css" href="/stylesheets/mobile_styles.css"> <style type="text/css"> <!-- @import url("/stylesheets/statefund_styles.css"); --> </style> <style type="text/css" media="handheld, only screen and (max-device-width: 480px)"> <!-- @import url("/stylesheets/mobile_styles.css"); --> </style> <link href="/stylesheets/statefund_styles.css" rel="stylesheet" type="text/css" media="screen and (min-width: 481px)"> </div> <div class='body-Content' id=""> <div class="topheader"><a href="/index.asp" name="home"><img src="/images/state_fund_logo.gif" alt="state fund logo" border="0" align="left"></a> <div class="offscreen"><img src="/images/offscreen_transparency.gif" alt="" width="250" height="20" align="center"></div> <ul id="accessibility" class="offscreen"> <li><a href="#skipnavigation" accesskey="0">Skip past navigation</a></li> <li><a href="#footer" accesskey="4">Skip to table of contents</a></li> </ul> <div class="offscreen"><img src="/images/offscreen_transparency.gif" alt="" width="250" height="20" align="center"></div> <div class="topheaderRight"> <div class="topnav"> <div class="topnavRight"><a href="/index.asp" accesskey="5">Home</a> | <a href="/contact/ContactUs.asp" tabindex="1">Contact us</a></div> <div class="topnavLeft"><a href="/employers/Index.asp" name="Employer">EMPLOYERS</a> | <a href="/broker/Index.asp" name="Broker">BROKERS</a> | <a href="/provider/Index.asp" name="Medical Provider">MEDICAL PROVIDERS</a> | <a href="/employees/Index.asp" name="Employee">EMPLOYEES</a> | <a href="/statecontracts/Index.asp" name="State Contracts">STATE AGENCIES</a></div> </div> <div class="topPhonenumber2"><a href="/CustomerSupport/Index.asp"><strong><font size="4px">Customer Support</font></strong></a><br>(888) 782-8338</div> <div class="topMission">Established in 1914 by the state legislature, State Fund is California's most reliable provider of workers' compensation insurance and a vital asset to California businesses. State Fund supports California's entrepreneurial spirit and plays a stabilizing role in the economy by providing fairly priced workers' compensation insurance, helping California employers keep their workplaces safe, and restoring injured workers. </div> </div> <br><br><br> </div> <div id="mainNav2"> <div id="mainNav3"> <div class="offscreen"><img src="/images/offscreen_search.gif" alt="" width="250" height="20" align="left"><br> <br> </div><div class="search"> <form name="search" action="https://search.scif.com/StateFundCAsearch.cgi" method="get"><input value="Search" name="query"></form> </div><div class="offscreen"><img src="/images/offscreen_transparency.gif" alt="" width="250" height="20" align="center"><br> </div><ul> <li><a href='/about/About.asp' name='About'>About</a></li><li><a href='/policy/ObtainAPolicy.asp' name='Obtain a Policy'>Obtain a Policy</a></li><li><a href='/claims/ClaimsSvcs.asp' name='Claims Services'>Claims Services</a></li><li><a href='/safety/SafetyAndSeminars.asp' name='Safety &amp; Seminars'>Safety &amp; Seminars</a></li><li class='on'><a href='/forms/Forms.asp' name='Forms'>Forms</a></li><li><a href='/careers/Index.asp' name='Careers'>Careers</a></li> </ul> </div> </div> <a name="skipnavigation"></a> <div class="mainArea"> <div class="subright"> </div> <div class="subleft"> <div id="subNav"> <ul> <li><a href='/forms/AllForms.asp'>All Forms</a></li><li><a href='/forms/Brokers.asp'>Broker Forms </a></li><li><a href='/forms/Suppliers.asp'>Corporate Supplier Forms</a></li><li><a href='/forms/Employees.asp'>Employee Forms</a></li><li><a href='/forms/Employers.asp'>Employer Forms</a></li><li><a href='/forms/Providers.asp'>Medical Provider Forms</a></li> </ul> </div> <div class="sidesubsubnav"> <div class="subheadr"></div> <ul> </ul> </div> </div> <div class="submiddle"> <div class="subright"></div><br> <sp> <h1>Employer Requirements</h1> <p>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.</p> <h3>Individual Form Links</h3> <p> You can view and download each individual <strong>form</strong> by clicking on the <strong>link(s)</strong> below.</p> <table border="1" cellspacing="2" cellpadding="5"> <tr> <td width="502" align="left"><strong>Required Materials</strong></td> <td width="62" align="center"><strong>Policy Inception</strong></td> <td width="57" align="center"><strong>Time of Hire</strong></td> <td width="59" align="center"><strong>Time of Injury</strong></td> </tr> <tr> <td width="502"><p><a href="/pdf/DWC7NoticePoster.pdf" target="_blank">Notice to Employees DWC 7</a> (Replaces State Fund Forms e13708 and e13709, English & Spanish)<br> <em>Notice to Employees DWC 7 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.<br> Before posting the notice, enter the following information below:<br> <span style="background-color:#CCC">State Fund MPN Website:</span> <a href="/claims/MPNHome.asp">www.statefundca.com/sfmpn</a><br> <span style="background-color:#CCC">MPN Effective Date:</span> 07/27/2020<br> <span style="background-color:#CCC">MPN Identification Number:</span> 3136<br> <span style="background-color:#CCC">MPN Access Assistant:</span> (888) 782-8338, Fax (800) 371-5905<br> <span style="background-color:#CCC">MPN Contact Person:</span> (877) 636-0606<br> <span style="background-color:#CCC">Claims Administrator:</span> State Compensation Insurance Fund;<br>Phone: (888) 782-8338<br> <span style="background-color:#CCC">Workers’ Compensation Insurance Carrier:</span> State Compensation Insurance Fund<br> <span style="background-color:#CCC">DWC’s Information & Assistance Office: </span><a href="https://www.dir.ca.gov/dwc/ianda.html" target="_blank">www.dir.ca.gov/dwc/ianda.html</a></em></p></td> <td width="62" nowrap="nowrap" valign="middle"><p align="center"><img src="/images/check.gif" alt="check" width="24" height="24"></p></td> <td width="57" nowrap="nowrap" valign="bottom"><p>&nbsp;</p></td> <td width="59" nowrap="nowrap" valign="bottom"><p>&nbsp;</p></td> </tr> <tr> <td width="502"><p><a href="/pdf/e3851.pdf" target="_blank">Employee’s Guide to State Fund MPN e3851</a> (Replaces State Fund form e13176, English & Spanish)<em><br> Must be provided to employee at time of injury, or where there is existing injury, and when transferring care into the MPN. Must be provided in both English and Spanish if the employee primarily speaks Spanish.</em> </p></td> <td width="62" nowrap="nowrap" valign="middle"><p align="center"><img src="/images/check.gif" alt="check" width="24" height="24"></p></td> <td width="57" nowrap="nowrap" valign="middle"><p align="center">&nbsp;</p></td> <td width="59" nowrap="nowrap" valign="middle"><p align="center"><img src="/images/check.gif" alt="check" width="24" height="24"></p></td> </tr> <tr> <td width="502"><a href="/pdf/e13286.pdf" target="_blank">New Employee’s Guide to Workers’ Compensation e13286</a></td> <td width="62" nowrap="nowrap" valign="bottom"><p align="center">&nbsp;</p></td> <td width="57" nowrap="nowrap" valign="bottom"><p align="center"><img src="/images/check.gif" alt="check" width="24" height="24"></p></td> <td width="59" nowrap="nowrap" valign="bottom"><p align="center">&nbsp;</p></td> </tr> <tr> <td width="502"><p><a href="/pdf/e3301.pdf" target="_blank">Workers’ Compensation Claim Form e3301</a> with instructions</p></td> <td width="62" nowrap="nowrap" valign="bottom"><p align="center">&nbsp;</p></td> <td width="57" nowrap="nowrap" valign="bottom"><p align="center">&nbsp;</p></td> <td width="59" nowrap="nowrap" valign="bottom"><p align="center"><img src="/images/check.gif" alt="check" width="24" height="24"></p></td> </tr> <tr> <td width="502"><p><a href="/pdf/3067.pdf" target="_blank">Employer’s Report of Occupational Injury or Illness 3067</a><strong><u><br> </u></strong><em>Must be completed and submitted to State Fund no later than 5 days from the date of knowledge of a work injury or illness.</em> </p></td> <td width="62" nowrap="nowrap" valign="middle"><p align="center">&nbsp;</p></td> <td width="57" nowrap="nowrap" valign="middle"><p align="center">&nbsp;</p></td> <td width="59" nowrap="nowrap" valign="middle"><p align="center"><img src="/images/check.gif" alt="check" width="24" height="24"></p></td> </tr> </table><br> <h3>PENALTIES</h3> <p> Per Title 8 California Code of Regulations (CCR) section § 9881 all California employers are required to display this poster 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. Non-compliant employers face potential penalties up to $7,000.</p> <h3>Claim Kit</h3> <p>For your convenience, we’ve grouped the forms needed to report a claim into a single downloadable <a href="/pdf/e13675.pdf" target="_blank">claim kit (PDF)</a>.</p> <h3>Call Us</h3> <p>If you have additional questions, please call our Customer Service Center at (888) 782-8338.</p> </sp> </div> <div style="clear:both"></div> </div> <a name="footer"></a> <div class="footerArea"> <div class="footerbg"> <ul> <li> <div class="footerSpacer"></div> <a href="/broker/Index.asp">Brokers</a> <br> <a href="/employers/Index.asp">Employers</a> <br> <a href="/employees/Index.asp">Employees</a> <br> <a href="/fraud/Fraud.asp">Fraud</a> <br> <br> </li> <li> <div class="footerSpacer"></div> <a href="/provider/Index.asp">Medical Providers</a> <br> <a href="/statecontracts/Index.asp">State Agencies</a> <br> <a href="/policy/ObtainAPolicy.asp">Obtain a Policy</a> <br> <a href="/about/VendorGuide.asp">Vendor Guide</a> <br> <br> </li> <li> <div class="footerSpacer"></div> <a href="/claims/ClaimsSvcs.asp">Claims Services</a> <br> <a href="/safety/SafetyAndSeminars.asp">Safety & Seminars</a> <br> <a href="/forms/Forms.asp">Forms</a> <br> <a href="/about/Community.asp">Community</a> <br> <br> </li> <li> <div class="footerSpacer"></div> <a href="/about/About.asp">About Us</a> <br> <a href="/about/history/index.html">History</a> <br> <a href="/contact/ContactUs.asp">Contact Us</a> <br> <a href="/CustomerSupport/Index.asp">Customer Support</a> <br> <br> </li> </ul> <div style="clear:left"></div> </div> </div> <div class="footerArea" align="center">Copyright &copy; 2000-2023 State Compensation Insurance Fund<br> <a href="/about/TermsOfUse.asp">Website Terms of Use</a>, <a href="/about/PrivacyPolicy.asp">Website Privacy Policy</a> and <a href="/about/SharingDisclosure.asp" target="_blank">Information Sharing Disclosure</a></div> </div> </div>