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EMPLOYER’S REPORT OF INJURY FORM Tutorial– Box Explanations

Form e3067

EMPLOYER INFORMATION

Employer’s Report of Injury Form (e3067)

1. FIRM NAME

Enter company name as indicated on your Annual Rating Endorsement or policy.

DIVISION

If applicable, provide the specific department or division where injury occurred.

1a. POLICY NUMBER

Include the group & policy number, or policy number with current year, separated with dashes or spaces. For example: 673-45-10 (group-policy number-policy year) or 1834567-10 (policy number–policy year).

2. MAILING ADDRESS

Use the address shown on your Annual Rating Endorsement or policy.

2a. PHONE NUMBER

 Provide your company’s primary contact phone number, including area code.

3. LOCATION

Indicate the physical address of where the injury occurred, including street address, suite # (if applicable), city and ZIP code.

3a. LOCATION CODE

If applicable, use the code corresponding to the location, department, or division where the injury took place.

4. NATURE OF BUSINESS

Provide a general description of your business.

4a. NUMBER OF EMPLOYEES ON THE DOI

The total number of employees working on the date of injury.

5. STATE UNEMPLOYMENT INSURANCE ACCOUNT NUMBER

Enter your State of California Unemployment Insurance account number, also known as your “State Tax ID Number” or “EDD Number” (Employment Development Department).

6. TYPE OF EMPLOYER

Place a check mark or “x” on the box that best describes your business (private, state, county, city, school district, other government).

INJURY OR ILLNESS INFORMATION

Employer’s Report of Injury Form (e3067)

7. DATE OF INJURY/ ONSET OF ILLNESS

For specific injuries (such as slip & fall), use the actual date when the incident happened. For injuries or illnesses that are results of exposure to continuous trauma, chemicals, stress, etc., over time, the appropriate date to use would be:

  1. The date of last exposure.
  2. The date of the injured worker’s first evidence of disability.
  3. The date indicated on the medical report if available.
  4. The employer’s date of knowledge if the date of injury can’t be determined.

8. TIME INJURY/ILLNESS OCCURRED

Enter the actual or approximate time when the injury happened. You may also use “unknown” if applicable.

9. TIME EMPLOYEE BEGAN WORK

Enter the time the injured worker started his/her shift on the day of injury/illness.

10. IF EMPLOYEE DIED, DATE OF DEATH

Enter date of death if the worker died as a result of his/her injuries/illness.

11. UNABLE TO WORK FOR AT LEAST ONE FULL DAY AFTER DATE OF INJURY

Choose “Yes” if the injured worker has missed one full day or more of work because of the injury.

12. DATE LAST WORKED

Enter the date that the injured worker last worked (month, day, year).

13. DATE RETURNED TO WORK

Enter the date the injured worker returned to work, if applicable (month, day, year). Leave blank if the injured worker has not yet returned to work, and check box 14.

14. IF STILL OFF WORK, CHECK THIS BOX

Check box if the injured worker is still off work at the time of this report’s completion.

15. PAID FULL WAGES FOR DAY OF INJURY OR LAST DAY WORKED

Check “Yes” if you paid the injured worker for a full day or “No” if you only paid for the hours worked.

16. SALARY BEING CONTINUED

Indicate here if the injured worker receives tips, overtime pay, meals, or other non-wages.

17. DATE OF EMPLOYER’S KNOWLEDGE/NOTICE OF INJURY/ILLNESS

Indicate the date you were first notified or became aware of the injury or illness (month, day, year). Please do not leave blank.

18. DATE EMPLOYEE WAS PROVIDED CLAIM FORM

Enter the date you provided the injured worker with the employee claim form (month, day, year).

19. SPECIFIC INJURY/ILLNESS AND PART OF BODY AFFECTED, MEDICAL DIAGNOSIS

Provide details about the worker’s injury/illness. Be specific as to which body part was affected and the type of injury.

20. LOCATION WHERE EVENT OR EXPOSURE OCCURRED

Enter the actual physical location where the injury occurred (street address, suite #  (if applicable),  city, ZIP code). If the injury happened at a job site, indicate that location’s address. If specific information is not available, enter “job site – address unknown.”

20a. COUNTY

Enter the County name where the injury occurred.

21. ON EMPLOYER’S PREMISES?

Check “Yes” if the injury occurred at your business location, or “No” if it occurred at a job site, public road, or other venue away from the main business location.

21a. WAS ANOTHER PERSON RESPONSIBLE?

Check “Yes” if another person was directly or indirectly responsible for the injury.

22. DEPARTMENT WHERE EVENT OR EXPOSURE OCCURRED

Enter the specific business location, such as warehouse, assembly area, kitchen, garage, or other work area.

23. OTHER WORKERS INJURED OR ILL IN THIS EVENT?

Check “Yes” if more than one employee was injured in this single occurrence or incident.

24. EQUIPMENT, MATERIAL, AND CHEMICALS THE EMPLOYEE WAS USING WHEN EVENT OR EXPOSURE OCCURRED

Detail any equipment, materials or chemicals the injured worker was handling or exposed to at the time of injury or illness.

25. SPECIFIC ACTIVITY THE EMPLOYEE WAS PERFORMING WHEN EVENT OR EXPOSURE OCCURRED

Briefly state what the injured worker was doing at the time of injury.

26. HOW INJURY/ILLNESS OCCURRED

Describe how the injury or illness occurred, providing as many details as available.

27. NAME AND ADDRESS OF PHYSICIAN

Enter the complete information for the doctor or medical facility providing the initial medical evaluation or treatment (first and last name, facility name, street address, suite # (if applicable), city, ZIP code).

27a. PHONE NUMBER

Enter the treating doctor or medical facility telephone number, including area code.

28. HOSPITALIZED AS AN INPATIENT OVERNIGHT? NAME & ADDRESS OF HOSPITAL

Check “Yes” if the injured worker was hospitalized overnight; provide hospital details if applicable (name, street address, city, ZIP code).

28a. PHONE NUMBER

Enter the phone number of the admitting hospital, including area code.

29. EMPLOYEE TREATED IN EMERGENCY ROOM?

Check “Yes” if the injured worker received initial treatment in the emergency room.

EMPLOYEE INFORMATION

Employer’s Report of Injury Form (e3067)

30. EMPLOYEE NAME

Enter the injured worker’s complete legal name (first, middle, last).

31. SOCIAL SECURITY NUMBER

Enter the injured worker’s social security number.

32. DATE OF BIRTH

Enter the injured worker’s complete date of birth (month, day, year).

33. HOME ADDRESS

Injured worker’s complete home address, including street address, apt. # (if applicable), city and ZIP code.

33a. PHONE NUMBER

Enter the injured worker’s home phone number, including area code.

34. SEX

Enter the injured worker’s gender.

35. OCCUPATION

Enter the injured worker’s job title or field of work.

36. DATE OF HIRE

Enter the date when the injured worker started working for your company (month, day, year).

37. EMPLOYEE USUALLY WORKS

Enter the injured worker’s regular or average hours worked.

37a. EMPLOYMENT STATUS

Enter the injured worker’s employment status at the time of injury (regular, full-time, part-time, temporary, seasonal, disabled, retired, laid-off, unemployed, on strike, other).

37b. UNDER WHAT CLASS CODE OF YOUR POLICY WERE WAGES ASSIGNED?

Enter the injured worker’s employee class code (as used for payroll) at the time of injury.

38. GROSS WAGES/SALARY

Enter the injured worker’s gross wages paid per week, month, or year.

39. OTHER PAYMENTS NOT REPORTED AS WAGES/SALARY

Indicate here if the injured worker receives tips, overtime pay, meals, or other non-wages.

*** Please remember to include your name, title, date, and signature to complete this process. ***

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