Accident Investigation Report of Supervisor 

This form should be used by the injured worker’s supervisor to evaluate the reported incident and secure a statement of a worker’s injury.

English and Spanish

Employee’s Claim for Workers’ Compensation Benefits (DWC1)

  • Employer must provide a workers’ compensation claim form (DWC1) to the employee within one working day after the work-related injury or illness is reported.
  • Injured workers must complete the first section of the DWC1 form and give it to their Employer.
  • The employee should make and keep a copy before the Employer has filled it out. This is called a temporary copy.
  • Once the employer has completed its portion, one copy should be given to the employee, one to PacificComp and one retained for the file.

English and Spanish

Employee Medical Care Refusal and DWC1 Receipt 

When an employee refuses medical care, this form should be used to document a refusal of medical attention and acknowledge that the employee was provided with a DWC1 Workers’ Compensation Claim form.

English and Spanish

Employers Report of Occupational Injury Form 5020

Policyholders should complete this form for all injuries reported to PacificComp. This 5020 form can also be completed for the Policyholder when a claim is reported using PacificComp’s 24-hour Injury Hotline (800-474-8080).

English

Initial Medical Referral to Physician from Policyholder 

Employers should send this form with the employee to the industrial clinic to advise that modified duty is available.

English

Wage Statement Form to Be Completed by Policyholder

Employers should use this form to list an injured worker’s weekly earnings in the year before the injury occurred. PacificComp bases its benefit payment to the injured worker in large part on that person’s earning history.

English