Workers’ Compensation Claim Kit – California

Who will handle your claims?

Your California claims will be handled by one of two offices, located at:

1100 Town and Country Rd.
Suite 550
Orange, CA 92868
Phone: (800)209-9819
Anca Trifa, Regional Director

2400 Lakeside Blvd.
Suite 200
Richardson, TX 75082
Phone: (800)527-5531
Mike Hicks, Regional Director

How to Report Workers’ Compensation Claims?

To report via the Internet: Log on to the Crum & Forster website at https://cfconnect.cfins.com. Use your assigned User ID and Password. If you do not have a current User ID, please contact your local Crum & Forster Claims or Marketing resource.

To report via e-mail:                          [email protected]
To report via fax:                                1-877-622-6218
To report claims via telephone:       1-800-690-5520

(7 day/24 hour toll free reporting line for all states)

  • In the event of a serious or fatal injury, notify the local claim office immediately by telephone.

What forms and pamphlets does the employer need to be aware of?
Effective October 8, 2010, all California employers are subject to the new workers’ compensation regulations addressing the posting of notice to employees (CCR9881-9881.1), written notice to new employees (CCR9880) and use of the new DWC-1 Claim Form/Notice of Potential Eligibility (CCR10139).

Posting of Notice to Employees (DWC-7): The posting notice (DWC-7- 1/16 Rev.) must be posted in English and Spanish at each California work site in a conspicuous location frequented by employees during the hours of the work day. Additionally, if an employer has implemented a Medical Provider Network (MPN), then the full MPN notification shall also be posted in both English and Spanish in close proximity to the posting notice (DWC-7). The DWC-7 Posting Notices can be found on our website at:
http://www.cfins.com/claims/workers-compensation-claims/

Written Notice to New Employees: Every employer shall provide to each new employee, either at the time of hire or by the end of the first pay period, a written notice concerning their rights, benefits and obligations under workers’ compensation law as outlined in CCR9880. The distribution must include a form that the employee may use as an optional method for notifying the employer of their choice to predesignate a “personal physician” per LC4600 and LC 4601. The California Division of Workers’ Compensation has published a new hire pamphlet that meets these requirements. It is called the “Time of Hire Pamphlet” and is available in English and Spanish.
English: http://www.dir.ca.gov/dwc/DWCPamphlets/TimeOfHirePamphlet.pdf
Spanish: http://www.dir.ca.gov/dwc/DWCPamphlets/TimeofHirePamphlet_Spanish.pdf

Copies of the Predesignation of Personal Physician form are available at
English:  http://www.dir.ca.gov/dwc/FORMS/DWCForm_9783.pdf
Spanish: http://www.dir.ca.gov/dwc/FORMS/DWCForm_9783_Spanish.pdf

DWC-1 Claim Form/Notice of Potential Eligibility (CCR 10139):   Employers must provide the revised DWC-1/Notice of Potential Eligibility form (1/16 Rev.) to the employee within one working day of receiving notice or knowledge of an injury resulting in lost time beyond the employee’s work shift at the time of injury or which results in medical treatment beyond first aid. Copies of the DWC-1 Claim Form/Notice of Potential Eligibility form are available at http://www.dir.ca.gov/dwc/DWCForm1.pdf

Additionally, if an employer has implemented a Medical Provider Network (MPN), the complete written Employee MPN Notification must also be provided to the employee at the time of injury.

5020 / Employer’s First Report of Injury:
If you report the claim via the Internet or by telephone, you do not need to fill out this form. If you report the claim via fax, complete the form below, and fax it to Crum&Forster at the fax number provided above.

California 5020 form:

CA Form 5020 2002 Version

What is the Waiting Period For Lost Wages in California?
The waiting period is 3 days. If the employee is off work for more than 14 days, the first 3 days are paid retroactively.

What are the Choice of Physician Rules in California?
If the employee does not predesignate a physician (prior to a work-related injury), the employer/insurer direct the medical care by utilizing the Medical Provider Network (MPN). If properly implemented, the insured/carrier will retain medical control through the life of the claim.

Medical Provider Network: The Medical Provider Network (MPN) is a great tool for employers to reduce their claim costs. We have two MPN options to choose from as displayed in the MPN Comparison Chart below. Please contact your Claims Account Executive to discuss the implementation process.

CA MPN Comparison Chart – Aug 2019

Preferred Provider Organization Network (PPO)
Crum & Forster has a PPO network available. Follow the instructions below to access the PPO Network:

Logon to the website at:   www.talispoint.com/conduent/cfi

  • Search by Provider Address, Name or Region
  • Select the Distance, Provider Type and Specialty
  • Results can then be exported to a directory or excel.
  • You can obtain a Map List or text message by selecting a specific provider

Where should all medical bills be sent?

Crum & Forster
PO Box 14801
Lexington, KY 40512

 

 

 

 

 

 

 

 

 

 

 

Important Websites:

 

Department of Industrial Relations: http://www.dir.ca.gov/

 

Multi-State Information: http://www.workerscompensation.com/