How to Report New Claims

Step 1:
Each Employee is responsible to immediately report to their Supervisor that they have injured themselves while working

Step 2:
If an EMERGENCY DIAL 911 and get Employee treated and call Company Nurse On Call 24/7 Hotline 1-888-375-9779 and give code "CSIG" AFTER treatment.

Step 3:
If not an emergency, Employee/Supervisor calls Company Nurse On Call 24/7 Hotline 1-888-375-9779 and give code "CSIG" with Employee present, BEFORE Employee leaves the premises. Then, Company Nurse will determine:

A. First Aid Advice Only – The Nurse obtains information about the incident and will provide advice, which the Employee is to follow. The Employee may return full time to their regular position. If medical situation worsens or does not improve, the Employee is to call back Company Nurse for appropriate medical referral.

B. Medical Referral – If the Nurse determines medical treatment is needed, they refer Employee to your district's designated Medical Facility; Employee then goes to designated Medical Facility for treatment (unless they have pre-designated their personal physician prior to the injury).

Step 4:
Company Nurse transmits Supervisor's Report of Injury to District Claims Coordinator; District Claims Coordinator reviews and completes missing data (i.e. wages, occupation, etc.) and completes New Claims Additional Information Required fax and sends fax to CCCSIG .

Step 5:
Employee returns copy of Work Status Slip to District Claims Coordinator:

1. Release to full duty
2. Released with Work Restrictions or limitations
3. No release to work
4. If work restrictions apply , the District Claims Coordinator will work to either modify the Employee's usual job or provide a Temporary Work Assignment , if possible and completing a Temporary Work Agreement for Work Related Injuries.

Step 6:
CCCSIG will mail Employee a DWC-1 Workers' Compensation Claim Form to complete immediately to begin the claim process. State law requires that this form be provided to the Employee or a dependent within one (1) working day of receiving notice or knowledge of any injury being work-related.

Step 7:
For Safety Prevention Focus – For All Incidents:
Supervisor complete CCCSIG form “Accident Investigation Form ”

WHAT TO DO WITH THIS FORM:
Fax To:  1-925-692-1137, ATTN:  Steve Webber
& Your District Claims Coordinator