WORKERS' COMPENSATION Claim Filing Process
If you are injured at work, please follow the steps below as soon as possible:
Step 1: Notify Your Supervisor
a. Notify your supervisor immediately about your injury or work-related illness.
Step 2: Schedule a Medical Appointment
a. Contact Kaiser On-the-Job Occupational Health Center right away to schedule an appointment and start your workers’ compensation claim.
Kaiser On-the-Job Occupational Health Center
10050 N. Wolfe Road, Suite SW1-190
Cupertino, CA 95014
Phone: (408) 236-6160
General Line: (800) 464-4000
Hours:
Monday–Friday: 8:30 a.m. – 5:00 p.m.
Closed for lunch: 12:30 p.m. – 1:30 p.m.
Closed on weekends and holidays
b. Bring the following form with you so Kaiser can treat you under the Districts Workers' Compensation program:
i. WC Treatment Authorization Form
Step 3: Complete the Required Forms
a. Please complete the following forms:
i. DWC-1 Form
iii. Form 5020
Step 4: Submit Your Paperwork
a. After completing all forms, please save them as PDFs and email them to [email protected]
b. Once we receive your paperwork, we will process and set up your workers' compensation claim.
Questions or Assistance:
Phone: 650-949-6224
Email: [email protected]
Additional Information
Group #: FHDA-01 (self-funded)
District Contacts:
Human Resources: 650-949-6224
Foothill Health Services: 650-949-7243 or 650-949-7117
De Anza Health Services: 408-864-8732
Kaiser On-The-Go Contact Information
Employee/Student Employee Injury Claim Process
Claims Administration:
Sedgwick CMS Company
P. O. Box 14535
Lexington, KY 40512-4535
Phone: 877-809-9478
Fax: 859-280-4950
Injured workers whom have been treated by U.S. HealthWorks should continue to be treated by the physicians at U.S. HealthWorks. New injuries will be directed to Kaiser Occupational Medicine Clinic effective May 1, 2017.
Facts about Workers' Compensation
Workers' Compensation Medical Leave Allowance Earning Codes: codes 254, 255,and 256 (Applicable only for contract employees)
WC Treatment Clinic Information(Cupertino Location)
WC Treament Clinic Information(Within California) Last Updated: Sep'24
Supervisor's Claim and Safety Report (To be completed by the injured worker's supervisor)