REPORT A CLAIM
The JPIA’s Claims Staff Coordinates the defense and/or settlement of all covered claims by or against the districts. Crucial to their efforts is cooperation by the members in the form of early reporting of all incidents.
If you wish to report a Liability or Property claim please call (800) 231-5742, fax information to (916) 786-0209, or E-Mail to Claims.
After 4:30 or on weekends/holidays, please contact Sedgwick staff – Jim Stewart at (916) 548-8283, or Casey McClintock at (916) 607-6360.
You may email new Workers’ Compensation claims (5020, DWC-1, etc.) to Workers’ Comp Claims.
The JPIA’s Claims Staff Coordinates the defense and/or settlement of all covered claims by or against the districts. Crucial to their efforts is cooperation by the members in the form of early reporting of all incidents.
If you wish to report a Liability or Property claim please call (800) 231-5742, fax information to (916) 786-0209, or E-Mail to Claims.
After 4:30 or on weekends/holidays, please contact Sedgwick staff – Jim Stewart at (916) 548-8283, or Casey McClintock at (916) 607-6360.
You may email new Workers’ Compensation claims (5020, DWC-1, etc.) to Workers’ Comp Claims.
Liability and Property Program Claims Information
Claim Incident Form (Auto Only) (Download this form to your computer before completing and sending it.) * For District Members Only *
Claim Incident Form (Non-Auto) (Download this form to your computer before completing and sending it.) * For District Members Only *
Claim Form * For Claimants*
Claim Incident Form (Auto Only) (Download this form to your computer before completing and sending it.) * For District Members Only *
Claim Incident Form (Non-Auto) (Download this form to your computer before completing and sending it.) * For District Members Only *
Liability and Property Program Claims Information
Claim Incident Form (Auto Only) (Download this form to your computer before completing and sending it.) * For District Members Only *
Claim Incident Form (Non-Auto) (Download this form to your computer before completing and sending it.) * For District Members Only *
Claim Form * For Claimants*
Claim Incident Form (Form in Word format) * For District Members Only *
Claim Incident Form (Auto Only) (Form in Word format) * For District Members Only *
Cyber Liability Claims Information
Cyber Liability Claims Information
Workers’ Compensation Program Claims Information
California Workers’ Compensation Law requires that every employer provide its employees with workers’ compensation coverage. This coverage guarantees state-mandated benefits to employees injured on the job or incurring work-related illness or disease. If you are unable to decide if an injury is work related, report it to the JPIA for investigation.
All incidents should be reported to us immediately by using the link below, or by faxing the workers’ compensation forms to the JPIA at (916) 786-0209. DO NOT send reports of any kind directly to the Department of Industrial Relations, Workers’ Compensation Appeals Board, any attorney or physician.
You may email new Workers’ Compensation claims (5020, DWC-1, etc.) to Workers’ Comp Claims.
Should you wish to send the paperwork through a secured email, and you are a new user you will need to create an account first.
For existing users Secure Message Portal click on the link here. When creating the secured email, please send the email to _claimswc_wa@acwajpia.com
You can find more information on the claims process and important forms for both JPIA members and outside claimants below.
Injury/Illness Claims Reporting Kit
Claim Form (DWC1) & Notice of Potential Eligibility
Claim Form (DWC1) & Notice of Potential Eligibility Fill in
Employer’s Report of Injury (5020)
Employer’s Report of Injury (5020) Fill in
A Guide to High-Value Physician Services in Workers’ Compensation (Revised 10/29/10)
Clinic Evaluation (Form in Word format)
Supervisor’s Accident-Incident Investigation Form
Frequently Asked Questions
Does workers’ compensation pay for time off to attend appointments?Suzanne Wallace2021-10-13T19:53:45-07:00
No. Workers’ compensation only covers time off when a doctor states an employee is unable to work. Employees will need to use sick or vacation time.
When am I required to post my Osha300a log?Suzanne Wallace2021-11-16T22:32:49-08:00
Posting is required from February 1 through April 30.
Where can I locate my local CalOsha reporting site?Suzanne Wallace2021-11-16T22:30:54-08:00
Refer to the link below. Just enter your zip code or city to find your local CalOsha reporting site.
https://www.dir.ca.gov/dosh/report-accident-or-injury.htm
What is considered a serious injury or illness by CalOsha?Suzanne Wallace2022-06-17T18:46:04-07:00
Definition of a serious injury is death, in patient hospitalization for reasons other than medical observation or diagnostic testing, amputation, loss of an eye or serious permanent disfigurement.
You are now required to report serious injuries sustained to a worker in a construction zone on a public highway.
Resource: JPIA Splash Alert, Cal/OSHA Adopts New Law Revising the Definition of a Serious Injury/Illness Employer Reporting Requirements Serious Injury Reporting Flow Chart
How much time do I have to report a serious injury to Cal Osha?Suzanne Wallace2021-11-16T22:25:51-08:00
Immediately but no longer than 8 hours of the known injury/illness.
Resource: 8 CCR 342 Reporting Work-Connected Fatalities and Serious Injuries.
Are we required to notify our employees yearly of their right to pre-designate?Suzanne Wallace2021-10-11T22:33:43-07:00
No, we recommend the “Facts About Workers’ Compensation” pamphlet be included in all new hire packets.
Can employees pre-designate a physician?Suzanne Wallace2021-10-11T22:34:24-07:00
Yes, but only before an injury occurs. If an employee desires to pre-designate a doctor, please provide the employee with the blue Facts About Workers’ Compensation pamphlet. The doctor is not required to sign the form, but they must supply other documentation that they are agreeing to be a pre-designated physician.
How do I change my designated clinic?Suzanne Wallace2021-10-11T22:35:09-07:00
Advise employees of the new clinic by updating your employment poster and send an email to the JPIA to advise of the new clinic information. When deciding upon a new clinic, the JPIA has a clinic evaluation check list and Guide to High-Value Physician Services in Workers’ Compensation on our website to assist employers with selecting a new initial care clinic. You may also consult with Occu-Med to get a list of clinics in your area.
What is Utilization Review (UR)?Suzanne Wallace2021-10-13T19:55:07-07:00
UR reviews treatment requests by the treating physician determines medical necessity. UR will determine whether to approve the requested treatment. Claims Administrators are required by law to have a UR program.
Do we pay for medical treatment during the delay process?Suzanne Wallace2021-10-13T19:54:33-07:00
Yes, up to $10,000 subject to utilization review until the claim is denied.
Why do I have to use my sick time when I attend medical appointments?Suzanne Wallace2021-10-13T19:54:11-07:00
TD benefits are paid when your treating physician indicates you are medically temporarily disabled. If you have returned to work and you are receiving your salary, then you are not medically disabled.
If we have an injured employee working modified duty and they are complaining the modified work is increasing their symptoms, what should we do?Suzanne Wallace2021-10-13T19:53:16-07:00
They need to get back into their doctor’s office immediately, you may need to pull them off the job until they are seen and then call your claims examiner.
We had an injured employee bring in a bill from his workers’ comp doctor advising him that he owes the difference of what workers’ comp paid and what was billed. What should I tell this employee?Suzanne Wallace2021-10-13T19:52:44-07:00
Tell the employee to call the JPIA, providers are not allowed to bill the patient on an accepted work related injury.
How are prescriptions paid?Suzanne Wallace2021-10-13T19:52:20-07:00
Medications for work injuries should be billed through MyMatrixx. Employees need to be provided with the First fill pharmacy form before they are sent to the Occupational Injury Clinic.
What if the doctor releases an injured worker back to modified duty full time but we only have part-time modified duty, should we still bring them back?Suzanne Wallace2021-10-13T19:51:53-07:00
Yes, even if you only have two hours of work it is always best to bring back the injured employee. We will pay them a temporary partial disability or wage loss benefit.
We have an injured employee who has been released back to modified duty which we can provide but the employee has declined the work. Can they refuse to work modified duty?Suzanne Wallace2021-10-13T19:51:26-07:00
Yes, they can, but we will not pay temporary disability benefits and they will need to use their own sick leave.
What do I do if an employee seeks treatment from their private care physician before reporting the claim?Suzanne Wallace2022-02-16T21:44:08-08:00
Once the employee reports they have suffered a worker related injury, you need to direct them to your clinic. If treatment is beyond first aid, you will then provide them with a DWC1 Claim Form. Any treatment sought prior to reporting a work-related claim is considered self-procured and will not be covered under the workers’ compensation claim. The late reporting of a workers’ compensation claim could result in the claim being placed on delay and investigated.
What if the validity of the claim is questionable?Suzanne Wallace2021-10-13T19:50:57-07:00
If you have a questionable claim, you need to let us know as we may need to formally delay the claim. This involves obtaining the injured worker’s statement and medical records. It also involves obtaining employer statements. We may also need a medical evaluation to make a compensability determination.
What should I send with the injured employee when I send them to our Occupational Injury Clinic?Suzanne Wallace2021-10-13T19:50:19-07:00
They should bring the medical referral card and the First fill pharmacy form. Or you can call the clinic to let them know you are sending the injured employee and then just send the First fill pharmacy form with the employee.
Do I need to provide a DWC1 claim form if the clinic indicates the treatment qualifies as first aid?Suzanne Wallace2021-10-13T19:49:55-07:00
Do I need to provide a DWC1 claim form if the clinic indicates the treatment qualifies as first aid?
No, but once treatment is beyond first aid, you then have 1 business day to provide the DWC-1 claim form.
What should I do if an employee is injured but doesn’t wish to seek medical treatment?Suzanne Wallace2021-10-13T19:49:13-07:00
Document date/time and what happened and have them sign that they are declining treatment. On the website, under documents there is a form titled “Declination of medical treatment”.
Workers’ Compensation Program Claims Information
California Workers’ Compensation Law requires that every employer provide its employees with workers’ compensation coverage. This coverage guarantees state-mandated benefits to employees injured on the job or incurring work-related illness or disease. If you are unable to decide if an injury is work related, report it to the JPIA for investigation.
All incidents should be reported to us immediately by using the link below, or by faxing the workers’ compensation forms to the JPIA at (916) 786-0209. DO NOT send reports of any kind directly to the Department of Industrial Relations, Workers’ Compensation Appeals Board, any attorney or physician.
You may email new Workers’ Compensation claims (5020, DWC-1, etc.) to Workers’ Comp Claims.
Should you wish to send the paperwork through a secured email, and you are a new user you will need to create an account first .
For existing users click on the link here. When creating the secured email, please send the email to _claimswc_wa@acwajpia.com
You can find more information on the claims process and important forms for both JPIA members and outside claimants below.
Injury/Illness Claims Reporting Kit
Claim Form (DWC1) & Notice of Potential Eligibility
Claim Form (DWC1) & Notice of Potential Eligibility Fill in
Employer’s Report of Injury (5020)
Employer’s Report of Injury (5020) Fill in
A Guide to High-Value Physician Services in Workers’ Compensation (Revised 10/29/10)
Clinic Evaluation (Form in Word format)
Supervisor’s Accident-Incident Investigation Form
Frequently Asked Questions
Does workers’ compensation pay for time off to attend appointments?Suzanne Wallace2021-10-13T19:53:45-07:00
No. Workers’ compensation only covers time off when a doctor states an employee is unable to work. Employees will need to use sick or vacation time.
When am I required to post my Osha300a log?Suzanne Wallace2021-11-16T22:32:49-08:00
Posting is required from February 1 through April 30.
Where can I locate my local CalOsha reporting site?Suzanne Wallace2021-11-16T22:30:54-08:00
Refer to the link below. Just enter your zip code or city to find your local CalOsha reporting site.
https://www.dir.ca.gov/dosh/report-accident-or-injury.htm
What is considered a serious injury or illness by CalOsha?Suzanne Wallace2022-06-17T18:46:04-07:00
Definition of a serious injury is death, in patient hospitalization for reasons other than medical observation or diagnostic testing, amputation, loss of an eye or serious permanent disfigurement.
You are now required to report serious injuries sustained to a worker in a construction zone on a public highway.
Resource: JPIA Splash Alert, Cal/OSHA Adopts New Law Revising the Definition of a Serious Injury/Illness Employer Reporting Requirements Serious Injury Reporting Flow Chart
How much time do I have to report a serious injury to Cal Osha?Suzanne Wallace2021-11-16T22:25:51-08:00
Immediately but no longer than 8 hours of the known injury/illness.
Resource: 8 CCR 342 Reporting Work-Connected Fatalities and Serious Injuries.
Are we required to notify our employees yearly of their right to pre-designate?Suzanne Wallace2021-10-11T22:33:43-07:00
No, we recommend the “Facts About Workers’ Compensation” pamphlet be included in all new hire packets.
Can employees pre-designate a physician?Suzanne Wallace2021-10-11T22:34:24-07:00
Yes, but only before an injury occurs. If an employee desires to pre-designate a doctor, please provide the employee with the blue Facts About Workers’ Compensation pamphlet. The doctor is not required to sign the form, but they must supply other documentation that they are agreeing to be a pre-designated physician.
How do I change my designated clinic?Suzanne Wallace2021-10-11T22:35:09-07:00
Advise employees of the new clinic by updating your employment poster and send an email to the JPIA to advise of the new clinic information. When deciding upon a new clinic, the JPIA has a clinic evaluation check list and Guide to High-Value Physician Services in Workers’ Compensation on our website to assist employers with selecting a new initial care clinic. You may also consult with Occu-Med to get a list of clinics in your area.
What is Utilization Review (UR)?Suzanne Wallace2021-10-13T19:55:07-07:00
UR reviews treatment requests by the treating physician determines medical necessity. UR will determine whether to approve the requested treatment. Claims Administrators are required by law to have a UR program.
Do we pay for medical treatment during the delay process?Suzanne Wallace2021-10-13T19:54:33-07:00
Yes, up to $10,000 subject to utilization review until the claim is denied.
Why do I have to use my sick time when I attend medical appointments?Suzanne Wallace2021-10-13T19:54:11-07:00
TD benefits are paid when your treating physician indicates you are medically temporarily disabled. If you have returned to work and you are receiving your salary, then you are not medically disabled.
If we have an injured employee working modified duty and they are complaining the modified work is increasing their symptoms, what should we do?Suzanne Wallace2021-10-13T19:53:16-07:00
They need to get back into their doctor’s office immediately, you may need to pull them off the job until they are seen and then call your claims examiner.
We had an injured employee bring in a bill from his workers’ comp doctor advising him that he owes the difference of what workers’ comp paid and what was billed. What should I tell this employee?Suzanne Wallace2021-10-13T19:52:44-07:00
Tell the employee to call the JPIA, providers are not allowed to bill the patient on an accepted work related injury.
How are prescriptions paid?Suzanne Wallace2021-10-13T19:52:20-07:00
Medications for work injuries should be billed through MyMatrixx. Employees need to be provided with the First fill pharmacy form before they are sent to the Occupational Injury Clinic.
What if the doctor releases an injured worker back to modified duty full time but we only have part-time modified duty, should we still bring them back?Suzanne Wallace2021-10-13T19:51:53-07:00
Yes, even if you only have two hours of work it is always best to bring back the injured employee. We will pay them a temporary partial disability or wage loss benefit.
We have an injured employee who has been released back to modified duty which we can provide but the employee has declined the work. Can they refuse to work modified duty?Suzanne Wallace2021-10-13T19:51:26-07:00
Yes, they can, but we will not pay temporary disability benefits and they will need to use their own sick leave.
What do I do if an employee seeks treatment from their private care physician before reporting the claim?Suzanne Wallace2022-02-16T21:44:08-08:00
Once the employee reports they have suffered a worker related injury, you need to direct them to your clinic. If treatment is beyond first aid, you will then provide them with a DWC1 Claim Form. Any treatment sought prior to reporting a work-related claim is considered self-procured and will not be covered under the workers’ compensation claim. The late reporting of a workers’ compensation claim could result in the claim being placed on delay and investigated.
What if the validity of the claim is questionable?Suzanne Wallace2021-10-13T19:50:57-07:00
If you have a questionable claim, you need to let us know as we may need to formally delay the claim. This involves obtaining the injured worker’s statement and medical records. It also involves obtaining employer statements. We may also need a medical evaluation to make a compensability determination.
What should I send with the injured employee when I send them to our Occupational Injury Clinic?Suzanne Wallace2021-10-13T19:50:19-07:00
They should bring the medical referral card and the First fill pharmacy form. Or you can call the clinic to let them know you are sending the injured employee and then just send the First fill pharmacy form with the employee.
Do I need to provide a DWC1 claim form if the clinic indicates the treatment qualifies as first aid?Suzanne Wallace2021-10-13T19:49:55-07:00
Do I need to provide a DWC1 claim form if the clinic indicates the treatment qualifies as first aid?
No, but once treatment is beyond first aid, you then have 1 business day to provide the DWC-1 claim form.
What should I do if an employee is injured but doesn’t wish to seek medical treatment?Suzanne Wallace2021-10-13T19:49:13-07:00