Monterey County
Risk Management


Government Center
168 W. Alisal St., 3rd Fl.
Salinas, CA 93901

Phone:
(831) 755-5045

Fax:
(831) 755-5081

Workers' Compensation

Print

CONTACTS

Risk Management
Workers' Compensation Coordinators
Intercare Holdings Ins. Services Claims Team


REPORTING A WORKERS' COMPENSATION INJURY

What To Do When an Injury Occurs Flowchart
Supervisor's Check List

Documents Needed to File Claim:

  1. DWC-1 Claim Form
  2. Privileged & Confidential Incident Investigation Report to County Counsel Form
  3. Job Description

    Department Location Codes
    Job Titles & WC Class Codes
  4. Form 5020

    See Department Location Codes for 5020 field #3A
    See Job Titles & WC Class Codes for 5020 fields 35 and 37B

Where to Submit Claim:

Intercare Holdings Insurance Services, Third-Party Administrator

Web: https://www.intercareins.com/WebLogin/default.aspx
Email: newclaims@intercareins.com
Fax: (877) 362-5050

Documents for Injured Worker

  1. Copy of Fully Signed DWC-1 Claim Form
  2. Medical Referral
  3. Physicians' Modified Work Activity Restriction Form


MEDICAL TREATMENT

County Authorized Treatment Facilities
Pre-Designation Form


MANDATORY NOTIFICATION POSTER

DWC-7 - http://www.dir.ca.gov/dwc/NoticePoster.pdf


INCIDENT TRACKING

Incident Log

 

 

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