Forms

• Audio-Visual Request Form e22160
• Claim FAX Coversheet
• Employee's Claim for Workers' Compensation Benefits (English/Spanish) e3301
• Employee’s Guide to The State Fund MPN e3851
• Employer's First Report of Injury - STATES 3067S
• Employer's First Report of Injury – CDCR 3580
• Employer's First Report of Injury – Department of State Hospitals 3581
• Guide to Workers' Compensation for State of California Employees 13561
• Medical Mileage Expense Form 3065
• New California State Employee’s Guide to Workers’ Compensation 13546
• New Disaster Service Worker's Guide to Workers' Compensation e13761
• Notice to Employees [DWC 7]
  • MPN Website: www.statefundca.com/sfmpn
  • MPN Effective Date: 07/27/2020
  • MPN Identification Number: 3136
  • MPN Access Assistant: (888) 782-8338, Fax (800) 371-5905
  • MPN Contact Person: (877) 636-0606
  • Claims Administrator: State Compensation Insurance Fund; Phone: (888)-782-8338
  • Workers’ Compensation Insurance Carrier: State Compensation Insurance Fund
  • DWC’s Information & Assistance Office: www.dir.ca.gov/dwc/ianda.html

• Safety Materials Order Form e22159