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Form Process <br /> • Provide Employee's Claim for Workers'Compensation Benefits form <br /> within 24 hours of notification of request for medical treatment and/or <br /> lost time <br /> • Enter date employer first knew of injury,which is the day the <br /> employee requested medical treatment and/or lost time <br /> • If the employee is not readily available to provide the Employee's <br /> Claim for Workers' Compensation Benefits form,the supervisor or <br /> manager must: <br /> o Complete the employer portion <br /> o Make copy of Employee's Claim for Workers'Compensation <br /> Benefits form indicating"date mailed" <br /> o Mail Employee's Claim for Workers'Compensation Benefits <br /> form to employee <br /> o Retain copy of Employee's Claim for Workers' Compensation <br /> Benefits form with Supervisor's Report of Accident and <br /> Employee Request for Medical Treatment forms <br /> D) Employer's Report The Employer's Report of Occupational Iniury or Illness form must also <br /> of Occupational Injury be completed and forwarded to Risk Management with the Employee's <br /> or Illness Claim for Workers'Compensation Benefits form within 5 working days <br /> of employer's knowledge date <br /> If on-line filing is available in your department,then a pre-authorized <br /> departmental user may file the Employer's Report of Occupational <br /> Injury or Illness form electronically.A copy of the submitted form <br /> should then be forwarded to Risk Management. <br /> Should the employee fail to return the Employee's Claim for Workers' <br /> Compensation Benefits form within the employer's timeline of 5 work <br /> days, do not delay submitting the Employer's Report of Occupational <br /> Injury or Illness form. Forward the retained copy of Employee's Claim <br /> for Workers'Compensation Benefits form,which indicates "date <br /> mailed",to Risk Management. <br /> E) Notice of Leave of If the injured employee is off work more than three days due to an on- <br /> Absence for Temporary the-job injury,the employee's supervisor or manager must provide <br /> Disability Indemnity Notice of Leave of Absence for Temporary Disability Indemnity Payment <br /> Payment form to the injured employee.The Notice of Leave of Absence for <br /> Temporary Disability Indemnity Payment form provides the department <br /> with the employee's decision regarding use of their accrued time and <br /> billing of their insurance premiums for the employee's dependents.The <br /> employee will complete the form and return it to their department.The <br /> Notice of Leave of Absence for Temporary Disability Indemnity Payment <br /> form shall be forwarded to the County Human Resources Department. <br /> On completion of the forms,follow the established guidelines to <br /> forward the forms. <br /> San Joaquin County <br /> Department of Public Works <br /> County of San Joaquin Dept of Public Works IIPP Rev 2020-01-31.docx P a g e 21 <br />