Workers' Compensation

REPORTING A WORKERS' COMPENSATION INJURY

What To Do When an Injury Occurs Flowchart
Supervisor's Check List

Documents Needed to File Claim:

1. DWC-1 Claim Form
2. Privileged & Confidential Incident Investigation Report to County Counsel Form
3. Job Description
   
   Department Location Codes
   Job Titles & WC Class Codes
4. Form 5020
   
   See Department Location Codes for 5020 field #3A
   See Job Titles & WC Class Codes for 5020 fields 35 and 37B

Where to Submit Claim:

Intercare Holdings Insurance Services, Third-Party Administrator

Web: Intercare Web Login (intercareins.com)
Email: newclaims@intercareins.com
Fax: (877) 362-5050

Documents for Injured Worker

1. Copy of Fully Signed DWC-1 Claim Form
2. Medical Referral
3. Physicians' Modified Work Activity Restriction Form
4. County of Monterey Employee Incident Report

MEDICAL TREATMENT

County Authorized Treatment Facilities
Pre-Designation Form

MANDATORY NOTIFICATION POSTER

DWC-7 - http://www.dir.ca.gov/dwc/NoticePoster.pdf

INCIDENT TRACKING

Incident Log

Free viewers are required for some of the attached documents.
They can be downloaded by clicking on the icons below.

Acrobat Reader Windows Media Player Word Viewer Excel Viewer PowerPoint Viewer