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State Fund is California's largest provider of workers' compensation insurance and a vital asset to California businesses. State Fund supports California's entrepreneurial spirit and plays a stabilizing role in the economy by providing fairly priced workers' compensation insurance making California workplaces safe, and restoring injured workers.



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Claims Kit

For your convenience and to help you comply with the law, we compiled the forms you’ll need to file a claim in an electronic Claims Kit (PDF). The chart below lists the forms and when to distribute them. You can also view and download the individual forms below:

Forms to File A Claim

Policy Inception

Time of Injury

Workers’ Compensation Claim Form e3301 with instructions

 

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Employer’s Report of Occupational Injury or Illness e3067
Must be completed and submitted to State Fund no later than 5 days from the date of knowledge of a work injury or illness.
 

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Employee’s Guide to the State Fund MPN by Harbor Health e3851
Must be posted at every worksite in a location that is easily visible to your employees. Must also be provided to employee at time of injury or, where there is existing injury, and when transferring care into MPN.

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Please refer to the Employer Requirements Page for a list of documents required to post and  distribute to employees at the Time of Policy Inception and at the Time Of Hire.

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If you have additional questions, please call our Customer Support Center at 888-STATEFUND (888-782-8338).

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