Workers’ Compensation Claim Reporting The Office of Risk Management Office of the Chief Risk Officer (OCRO) Workers’ Compensation Claim Reporting For Winter Closure 2017-2018 The Office of Risk Management December 1, 2017 Nicole Guevara, Return to Work Consultant Vanessa Cordova, Administrative Associate – Workers’ Compensation Claims

How to Report Workers’ Compensation Claims for Winter Closure 2017-2018 Call Zurich to report the claim within 24-hours of occurrence: Contact number: 800-987-3373 Provide them the same information as on the 5020 form: https://web.stanford.edu/dept/Risk-Management/docs/forms/5020.html If you do not have all the info, provide what you do know (including contact info for the injured/ill worker) - Zurich will investigate Follow the usual procedures for completing required Workers’ Comp forms: Step Directions 1. Provide the SU-17 to the employee and supervisor/University contact for their completion and signature within 24 hours of the occurrence (except in situations where stress or mental illness are part of the condition). Please make sure the medical evaluation section has been completed on the employee page. Submit the SU-17 via secure: email or fax to Vanessa Cordova in Risk Management: Email: VCordova@Stanford.edu; Fax (650) 723-9456 2. If the employee deemed treatment unnecessary and/or did not lose time from work, only the SU-17 will need to be submitted to Risk Management per the SU-17 submission instructions above. However if the employee sought treatment and/or lost time from work, please follow the instructions below for the 5020 and DWC 1 forms completion and submission. 3. Provide the employee the DWC 1 form per the instruction page and hand or mail it to the employee within 24 hours of the occurrence along with the Notice of Potential Eligibility pages. 4. Please have an employer representative (department administrator, supervisor or HR representative) complete the 5020 form (Employer’s Report of Occupational Injury or Illness). This must be typed and cannot be done by the employee. 5. Submit the provided/completed DWC 1, SU-17 and 5020 forms via secure: email or fax to Vanessa Cordova in Risk Management: 6. Once the paperwork is completed and submitted to Risk Management, please keep a copy for the department’s usual Workers' Compensation contact. There is no longer a requirement to also send the originals in addition to copies to Risk Management in ID mail.

Contact the Office of Risk Management Questions? We’re here to help! Contact the Office of Risk Management Nicole Vargas Guevara Return to Work Consultant nsvargas@stanford.edu 650-721-4348 Vanessa Cordova Administrative Associate, Workers’ Compensation Claims vcordova@stanford.edu 650-723-7400