Employers will need to submit a workers' compensation packet. A workers' compensation packet consists of:
Forward all forms to Risk Management: sjcriskmgmt@sjgov.org
San Joaquin County’s Third-Party Administrator (TPA), approves and authorizes worker’s compensation benefits. The TPA will have a period of time in which to accept, deny or delay a claim. This period of time is the “determination period”. The injured worker may elect to use their leave accruals during this period. The injured worker must complete a “Notice of Leave of Absence for Temporary Disability Indemnity Payment” (Form 29). If the injured worker is not available to complete this form, please mail or email to the injured worker for completion.
Worker’s Compensation Leave runs concurrently with Family Medical Leave Act (FMLA). For information on FMLA, see “Request for Leave of Absence form. (RLOA)
Temporary Disability Indemnity Payments will begin when the workers’ compensation claim is approved by the TPA. Risk Management will coordinate the disbursement of the Temporary Disability Indemnity Payments. Amounts are based on the employee’s average weekly wage. Please note that claims which involve lost time from work require a three-day waiting period before the start of Temporary Disability Indemnity Payments. If an injured worker is off work more than 7 days or requires immediate hospitalization this waiting period will be waived.
It is the injured worker’s responsibility to provide Manager/Supervisor any and all medical documentation for the workers’ compensation claim. Documents should include and are not limited to doctor’s first reports, work status reports, leave from work and work restriction notes. Provide Risk Management a copy of all documents received. Failure to submit doctor’s note may cause delay in Temporary Disability (TD) benefits to the injured worker.
Labor Code 5401
Within one (1) working day of receiving notice or knowledge of injury/illness, which results in lost time beyond the date of injury or which results in medical treatment, the Manager/Supervisor shall provide, in person, by mail or by email, a Employees Claim for Workers Compensation Benefits form (DWC1).
The injured worker must complete the employee section:
The Employer must complete the employer section:
If DWC1 was mailed to injured worker, submit copy indicating “date mailed” along with original documents. Do not delay submitting forms pending receipt of the original DWC1. The Employer has been placed on notice of an injury/illness. When the DWC1 is received from the injured worker, forward the form to Risk Management.