1. FIRMNAME

o

I !::ilaleOI.UlIlOm,a

EMPLOYER'S REPORT OFOCCUPATIONALINJURYOR ILLNESS

Pleasecomplete in triplicate(type if possible)mail two copias to: ICENTRAL SAN JOAQUIN VAL~EY RISK MANAGEMENT AUTHORITY

Administrated by: ACCLAMATlO~ INSURANCE MANAGEMENT SERVICES559-227-9891 • P.O. Box 28100· Fresno, CA93729 FATALITY

OSHACASE NO.

Any person who makes or causes to be made anyknowingly false or fraudulent material statement ormaterial representation for the purpose of obtaining ordenying workers compensation benefits or payments isguilty of a felony.

California law requires employers to report within five days of knowiedge every occupational injury or illness which results in lost time beyond thedate of the incident OR requires medicallrealmen~beyond first aid. If an employee subsequently dies as a result of a previously reported injury orillness, the employer must file within five days of ~Owledge an amended report indicating death. In addition, every serious injury, illness, or deathmust be reported immediately by telephone or telegraph to the nearest office of the California Division of Occupational Safety and Health.

II Ia, Policy Number

2a. Phone Number

Please do not usethis column

; 2. MAILINGADDRESS: (Number, Stree~ City, Zip) I~~3•.~LOnC~A"Tr.IOnN~W~d~~~~~n~trro~m~M~ai"'lin~g~A"d"d~~~~~(Nu.u~m~b~e~~.ST.tr~u~~'C",ity~a=nd7TZi=p')------~----------~I----------------------~h3a~L~O~~~ti~·o=nrC~o••de~--------------1~-- __ ~~~~~

o OWNERSHIP

:h4,.NAu.r,TnU~R~ErO~F~BmU~SlmN~E~SSo.;~.~.g~"DPa~in~t~in=g~co~n~tr~aa~M~,wn="-o~le~s~~~e~gr~o~ce~r,~s~aw~m=i"'I/,'h~o'-te'I,~et~c'--------------'I----------------------~~5'.~SU~t.~u~n~em=p~l~o~~e~nTti~n~su~r~an~~~a~cc~L~n~o-i

Oily I DSthcolDiSlricl

CASE NUMBER

6..TYPEOF EMPLOYER: 0 D DPrivale Slate oumy OherGOyt, Spoolfy:

INDUSTRY

7.DATEOFINJURYIONSETOFILLNESS8. TIME INJURynLLNESS OCCURRED(mmlddlyy)

PM PM

SEX

AM

9.TIMEEMPLOYEEBEGANWORKI AM

10.IFEMPLOYEEDIED,DATEOFDEATH(mmlddlyy)I---,====,.--lOCCUPATION

11.UNABlfTOWORKFORATLEASTONE12. DATELASTWORKED(mmlddlyy) 3 DATEReTuRNEDTOWORK(mmlddlyy) 14.IFSTilL OFFWORK,CHECKTHISBOX:FULLDAYAFTEI}I!AI;OFINJURY? . I DDes UNO15.PAIDFULLDAYSWAGESFORDATEOF 16.SALARYBEINGCONTINUED? 17.DATEOFEMPLOYER'SKNOWlEDGE/NOTICEOF 11.DATEEMPLOYEEWASPROVIDEDClAIMFORMNJURYORlASTO 0 Dyes DNa INJURynllNESS(mmiddlyy) FORM(mmlddlyy)DAYWORKED? Yes No I

I 19.SPECIFICINJURYlilLNESSANDPARTOFBODYAFFECTED,MEDICALDIAGNOSISff available,e.g..Secondde91 bumson right arm, lendonilis on left elbow,leadpoisoning

~"'~__ m_"~,"~"_m.".~._,".•" "''''T ".""O~::"'·"[j:'y 22.DEPARTMENTWHEREEVENTOREXPOSUREOCCURRED,e.g•.ShippIngdepartment,machineshop. I p3. OtherWorl<ersinjuredor ill in thi~?

IDes LJNo

AGE

DAILY HOURS

DAYS PER WEEK

o 24. EQUIPMENT, MATERIALS AND CHEMICALS THE EMPLOYEE WAS USINGWHEN EVENT OR EXPOSURE OCCURRED, o.g•. Acetylene, welding. torch, farm tractor, scaffold

R IWEEKLY HOURS

5. SPECIFIC ACTIVITY THE EMPLOYEEWAS PERFORMINGWHEN EVENT OR EXPOSURE OCCURREDI e.g.. Welding seams of metal forms, loading boxes onto truck.

ILL 1:2"'6."'H=OW=IN"J'"'UR"'y"'n"ll"'N"'ES"'S"'0""C"'C::":'UR:::RE=O-:.O""E=SC:::R/"'a"'E"'S"'E=a"'UE"'N"'C"'e-=O':'F:::EVE=NTS=-.""SP"'E"'C"'IFY=O=BJ"'E=Cr::'O:::R;:"EXP==O:::SU"'R"'E"'WH=IC=O"'IR"'E=CTL=Y-=P"'RO:::O:;:'U"'C""EO;:"TH=E"IN"'J"'UR:::Y:;;;II"lL"'N"'E"'SS::-,:-e.g:-.."W"'o"'rI<":'er:-:st::':e":'pped=L:ba=c::'kl::o-::ins=pe=ct::wc=rI<-iN and slipped on scrap material. As he fell. he brushed against fresh weld, and burned right hand. USE SEPARATE SHEET IF ECESSARYE5S

WEEKLY WAGE

COUNTY

NATURE OF INJURY

PARTOF BODY

A.TTENTION This form contains information relating to employee health and must be used in a manner that protects the confidentiality of employees to the extent possiblewhite the information is being used for occupational safety and health purposes. See CCR Title 8114300.29 (b)(6)-(10) & 14300.35(b)(2)(E)2.Note: Shaded boxes Indicate confidential employee InformatIon as listed In CCR TrUe 8 14300.35(b)(2)(E)T.

SOURCE

32.DATE-OF,!IIRTll (min/dl\fy)'l .....•. 31. SOcr,\LSECURlTY NU;>ffiER

, . EVENT

E 3J; HOMEA!iDREss lNulnb.r, Street, Ci1:)',Zip) . . JI

~~~~~~,~,.,~~---~:~~~~.~.~... ~~~~~~~~~.~.~~~ ..~~.~--------~--~--~~~--~--~~~~'~~~.'~.,~.~L .3>t:Sl'x, ... ' •...... ", .. ' .... ,... .•'.135. OCCUPATION(Regular job title, NO initials, abbreviations or nurnoers) ss, DATE01' IDREImmjd:!'YJ)

E~3g~;;~EJ5L::~sl . 37a.EMPloYMENTSTATUS 7b.UNDERWHArCLASSCODEOFYOUR

D~gular. full.time 0part-time POUCYWHEREWAGESASSIGNEDE hours per day, days per wuk, total weokly hours I

Dtemporary 0 seasonalI

33a. PHONE,NUMBERSECONDARYSOURCE

Completed By (type or print)

EXTENT OF INJURY

3B. GROSSWAGES/SALARY$ per

39.OTHE~PAYMENTSNOr REPORTEDASWAGESISALARY(e.g.tips,meals,overtime,bonuses,etc.)?

Dies DNO

Date (mmldd/yy)Signature & Title

• Confidential information may be disclosed only to the amp! yee, former employee. or their personal representative {CCR Title 8 14300.35}, to oUters for the purpose of processing a workers' compensation or other insuranceclaim; and under certain circumstances to a public he~th or law enforcement agency or to a consultant hired by the employer (CCRTitle 8 14300.30). CCRTitle 8 14300.40requires pnovision upon request to certain slate and

( Lf~ed~e~r~a~lw~o~~~pl~a~ce~s~~~ety~a~g~en~c~ie~s~. -:- . ~

FORM 5020 (Rev7) June 2002 I FILING OF THIS FORM IS NOT AN ADMISSION OF LIABILITYDISTRIBUTION: WHITE=WORKERS' COMPENSATION· CANARY=WORK~RS' COMPENSATION· PINK=PERSONNEL DEPT