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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
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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
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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