Care West Form Packets                                                   

 5020 Online Form  |  DWC1 Online Form

New Claim Packet

Contains: Claim Protocol, Supervisor's Investigation Report, 5020, Fraud Statement, DWC-1, Medical Authorization

Use: Employer should follow the claim protocol, and fill out the 5020 and Supervisor's Investigation Report. The rest of the forms should be given to the injured employee. Upon receipt of the forms from the employee, the employer should fill out the bottom section of the DWC-1, while the employee completes the Supervisor's Investigation Report. The paperwork should be reviewed to make sure it is completely and correctly filled out and then faxed to 209-574-2839 and 949-673-0362.

Declination of Medical Treatment Packet

Contains: Supervisor's Investigation Report, Declination of Medical Treatment, DWC-1

Use: Some employees do not wish to pursue treatment for a variety of reasons, however, a DWC-1 must still be given to the employee. The declination is verification for employer records. If in the future the employee seeks Workers' Compensation benefits, the employee should then fill out the DWC-1 and notify the employer.

First Aid Packet

Contains: First Aid Guidelines, WCIRB Reporting Notice, Supervisor's Investigation Report, 5020

Use: In any incident where only first aid treatment is provided, the employer should review the first aid guidelines and reporting requirements, then fill out the 5020, Supervisor's Investigation Report and fax them to 209-574-2839 and 949-673-0362. If the claim is a first aid it will not affect the experience modifier.

New/Current Employee Packet

Contains: Fraud Statement, Employee MPN Acknowledgement, MPN Welcome Letter, Predesignation of Personal Physician Form, MPN FAQ, MPN Policies

Use: Every new employee needs to be given this Workers' Compensation information at time of hire. Also, when employers become insured by Care West, the company must ensure that all current employees receive this packet. MPN information must be given in English and Spanish.

MPN Employer Packet

Contains: Important MPN Information, Employer MPN Acknowledgement, Summary of Predesignation Rules, Employee MPN Acknowledgement, MPN Welcome Letter, Predesignation of Personal Physician Form, MPN FAQ, MPN Policies

Use: Employer's must give MPN notice to all employees, new and current. This packet will guide employers on how to do this. The New/Current Employee Packet include everything needed to meet MPN notice guidelines.

OSHA 300 Log Packet

Contains: OSHA 300 Instructions, OSHA 300 Log, OSHA 300A Log, OSHA 301 Log

Extra: Interactive OSHA Log in Excel (Includes 300, 300A, and 301)

Use: The OSHA 300 log must be available if requested. The OSHA 300A log must be posted February 1 to April 30 of the year following the year covered by the form and be reported to OSHA if requested. The OSHA 301 is an optional incident report.

Other Useful Care West Forms

Wage Statement - Filled out when a claim becomes an indemnity/lost time claim. A Care West examiner will request one when necessary.

MORE COMING SOON!