Employee Physician Pre-Designation Form

This form allows employees to designate the physician who they want to receive treatment from in the event of a workplace injury or illness. We recommend this be included as part of an employee on-boarding process or included in the Human Resources (HR) handbook. When completed, this form should be submitted to the employee’s HR Department and maintained in their personnel file. It must be completed prior to an injury to be valid.

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Employee Pre-Designation Form for Personal Chiropractor or Acupuncture

If you are not currently enrolled in a PacificComp Medical Provider Network (MPN), your employees can pre-designate a chiropractor or acupuncturist after the employee obtains initial treatment with your employer-designated physician. The employer is then required to allow the employee to go to his/her pre-designated physician. This form can be used for notice, and it must be completed prior to an injury to be valid.

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Posting Notice for Policyholder (DWC-7)

California law requires that all employers post a copy of this document at the place(s) where employee notices are usually posted. It summarizes employees’ rights with regard to workers’ compensation benefits, steps to take in the event of an injury, and your company’s PacificComp MPN and claims information.

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Return to Work Program of Policyholder

Employers use this form to notify new employees of the return-to-work program. It may be included in your HR handbook.

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