Within 24 hours of knowledge of an injury, you will need to provide the injured worker with the DWC-1 Form, Employee’s Claim for Workers’ Compensation Benefits. Have the injured worker complete the top portion of the form and return it to the appropriate Supervisor or Manager. The employer will then complete the bottom portion of the document and give the injured worker a copy.

Next, you will need to complete the 5020 Form, Employer’s Report of Occupational Illness or Injury. The 5020 form and the DWC-1 form can be downloaded by clicking on the links on this page.

Once both of these documents are filled out, they need to be faxed to Risico. Documents can be faxed at any time, 7 days a week. Or, claims can be reported by telephone to our operators, Monday through Friday, between the hours of 8:00 a.m. and 5:00 p.m., PST.

Please be sure to keep a copy of both the DWC-1 and 5020 documents for your records.

California law requires that employers report within five days of knowledge a claim for an occupational injury or illness that results in lost time from work beyond the date of the incident OR requires medical treatment beyond first aid. Failure to report claims timely can jeopardize Risico’s ability to promptly investigate an injury, and can lead to unnecessary and excessive medical and disability costs, state penalties and fines, and a higher likelihood of litigation. Your cooperation in prompt reporting is a key factor in managing your Workers’ Compensation insurance expenses.

DISCLAIMER

Any person who makes or causes to be made any false or fraudulent material statement or material representation for the purpose of obtaining or denying Workers’ Compensation benefits or payments is guilty of a felony.

Download Forms

DWC-1 Form, Employee’s Claim for Workers’ Compensation Benefits

5020 Form, Employer’s Report of Occupational Illness or Injury

For AmTrust/Security National Ag Program Claims:

5020 Form, Employer’s Report of Occupational Illness or Injury