How to Fill Out and Submit California Form 5020 for Workers’ Comp

California Form 5020, the Employer’s Report of Occupational Injury or Illness, is the document you file with your workers’ compensation insurer (or, if you are self-insured, directly with the state) to report a workplace injury or illness. You have five days from the moment you learn of the incident to complete and submit it.¹ The current version, Form 5020 Rev. 7, is available as a PDF from the California Department of Industrial Relations.²

When Filing Is Required

You must file Form 5020 whenever a workplace injury or illness crosses either of two thresholds: the employee misses work beyond the day the incident happened, or the employee needs medical treatment that goes beyond basic first aid.¹ A trip to a doctor for stitches, a prescription, or diagnostic imaging triggers the requirement even if the employee returns to work the next day. You also must file when an injury or illness is only alleged to have arisen out of employment, so a disputed claim still requires a report.

First aid, for these purposes, means one-time treatment and any follow-up observation visit for minor injuries like small cuts, scratches, burns, or splinters. Physical therapy, prescription medications, and multiple diagnostic visits fall outside that definition. When in doubt, file. A submitted form that turns out unnecessary is far less trouble than a late one.

If an employee later dies from a previously reported injury or illness, file an amended Form 5020 indicating the death within five days of learning about it.¹

What to Gather Before You Start

The form has 39 numbered questions. Pulling the following information together first saves time and reduces errors:

Employer details: firm name as it appears on your workers’ comp policy, mailing address, physical location address, nature of business, state unemployment insurance account number from the EDD, workers’ compensation policy number, phone number, and type of employer (private, state, county, city, school district, or other government).²
Employee details: full name, Social Security number, home address, date of birth, occupation, hours and days normally worked, employment status (full-time, part-time, seasonal, or temporary), and the policy class code where wages are assigned.¹
Wage information: gross wages or salary for the pay period, plus any other payments not reported as wages, such as tips, meals, overtime, or bonuses. Cross-check these against payroll records, because the figures feed disability indemnity calculations.
Incident details: date and time the injury or illness occurred, the time the employee started work that day, the exact location (street address, city, zip, county), whether the incident was on your premises, and the department where it happened.
Injury description: the specific body part affected, medical diagnosis if available, equipment or materials involved, what the employee was doing immediately before the event, and a narrative of how it happened.
Work status: whether the employee missed at least one full day after the injury date, the last day worked, the return-to-work date (or a checkbox indicating still off work), whether you paid full wages for the injury date, and whether salary is being continued.

Handle the DWC-1 claim form first. California law requires you to give or mail the DWC-1 to the injured worker within one working day of learning about the injury.³ Question 18 on Form 5020 asks for the date you provided that claim form, so getting the DWC-1 to the employee immediately gives you a clean answer when you sit down with Form 5020.

Filling Out the Form

The layout runs top to bottom in a workable order: employer information first, then the incident and injury narrative, then employee wage and schedule data, and a signature block at the end.

Employer and Policy Information (Questions 1–6)

Enter your firm name exactly as it appears on your workers’ compensation policy. Question 2 is for your mailing address, Question 3 for the physical site if it differs. Question 1A takes the policy number your insurer assigned when coverage began. Question 5 asks for your state unemployment insurance account number from the EDD. Question 6 is a checkbox row for employer type; most private businesses check “Private.”

Injury and Incident Details (Questions 7–26)

Questions 7 and 8 capture the date and time of injury or symptom onset. For a repetitive-strain or occupational-disease claim, use the date the employee first noticed symptoms or the date a physician diagnosed the condition, whichever is appropriate. Question 17 records the date you, the employer, first learned of the injury. That date starts your five-day clock.

Question 19 asks for the specific injury, body part, and medical diagnosis if you have it. Write in plain terms: “laceration to left index finger” or “lower back strain.” Questions 24 through 26 are the narrative core. Name the equipment or chemicals involved, describe what the employee was doing, and lay out the sequence of events. Be concrete. “Employee was operating a table saw to cut plywood when the blade caught and lacerated the left index finger” tells the insurer far more than “cut hand on machine.”

Employee and Wage Information (Questions 27–39)

Questions 37 and 37A cover the employee’s usual schedule and employment status. Question 38 asks for gross wages or salary; report the figure that matches the pay period you select (hourly, daily, weekly, monthly, or yearly). Question 39 covers additional compensation such as tips, overtime, bonuses, or the value of meals and lodging. These wage fields drive temporary disability benefit calculations, so accuracy here matters more than almost anywhere else on the form.

Signature

Print or type the name of the person completing the form, sign, add your title, and date it. The form carries a fraud warning: knowingly making a false statement to obtain or deny workers’ compensation benefits is a felony under California law.⁴

Where to Send Form 5020

Where the completed form goes depends on how you carry coverage:

Insured employers file with their workers’ compensation insurance carrier within five days of learning about the injury or illness. The insurer then forwards a copy to the Division of Labor Statistics and Research immediately upon receipt.⁵
Self-insured employers file directly with the Division of Labor Statistics and Research within the same five-day window.¹

Most insurers accept the form through a secure online portal, email, fax, or mail. Use whatever method gives you proof of delivery: a portal timestamp, a fax confirmation page, or certified-mail tracking. That proof is your defense if anyone later questions whether you filed on time. Keep a copy for your own records before sending it.

Serious Injuries and Deaths: Report to Cal/OSHA Within Eight Hours

A serious injury, serious illness, or fatality triggers a separate, faster obligation that runs in parallel with Form 5020. You must notify Cal/OSHA immediately, meaning no longer than eight hours after you know or reasonably should have known about the incident.⁶ If you can demonstrate exigent circumstances, the window extends to 24 hours.

Cal/OSHA encourages telephone reports, and its hotline operates around the clock. Email is also accepted when you cannot call.⁷ The regulation also contemplates an online reporting mechanism, but the Division has not yet made one available, so telephone and email are the current methods.¹

Have this ready when you call: date and time of the incident, your company name and address, the name and address of the injured employee, the nature of the injuries, where the employee was taken for treatment, and a description of how the event unfolded.⁷ This call does not replace Form 5020. You still owe the completed written report to your insurer within five days.

Penalties for Late or Missed Reports

Failing to immediately report a serious injury, illness, or death to Cal/OSHA carries a civil penalty of at least $5,000.¹ That is a floor per incident; the actual penalty can go higher depending on severity and whether the failure was willful.

Beyond the statutory fine, late filing of Form 5020 stalls the whole claims process. Your insurer cannot evaluate the claim, authorize treatment, or start temporary disability payments until it has the report. Withholding a report because you doubt the claim, or discouraging an employee from filing to protect your premium, creates additional legal exposure. The obligation to report exists regardless of whether you believe the claim has merit.

Keeping Copies

Keep a copy of every completed Form 5020 in your files. California requires employers to retain Cal/OSHA injury and illness records for five years following the end of the calendar year they cover.⁸ That regulation names the OSHA log forms specifically rather than Form 5020, but applying the same five-year minimum to your 5020 copies is sound practice. Workers’ compensation claims can be reopened years after the original incident, and having the contemporaneous employer report on hand protects you during audits, insurance renewals, and any later dispute. Electronic storage is fine as long as records can be printed or displayed on request. Organize files by year and employee name so retrieval is quick.

1
California Legislative Information. California Labor Code LAB 6409.1
2
California Department of Industrial Relations. Form 5020 Employer’s Report of Occupational Injury or Illness
3
Department of Industrial Relations. DWC – How to File a Claim
4
Department of Industrial Relations. California Code of Regulations Title 8 Section 14005 – Reproduction of the Employer’s Report
5
Department of Industrial Relations. California Code of Regulations Title 8 Section 14002 – Insurer
6
Department of Industrial Relations. California Code of Regulations Title 8 Section 342 – Reporting Work-Connected Fatalities and Serious Injuries
7
Department of Industrial Relations. Report a Work-Related Accident – Employers
8
Department of Industrial Relations. California Code of Regulations Title 8 Section 14300.33 – Retention and Updating