20/2/2018 Forms

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State Fund is California's largest provider of workers' compensation Customer Support

insurance and a vital asset to California businesses. State Fund supports
888-STATEFUND (888-782-8338)
California's entrepreneurial spirit and plays a stabilizing role in the
economy by providing fairly priced workers' compensation insurance
making California workplaces safe, and restoring injured workers.

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ALL FORMS PRINT VERSION

EMPLOYER FORMS

BROKER FORMS
EMPLOYER REQUIREMENTS
EMPLOYEE FORMS
As an employer, you are required by law to provide your employees notice about their
STATE FUND ONLINE
MEDICAL PROVIDER FORMS workers’ compensation benefits, MPN providers, and where to seek treatment for
workers’ compensation injuries. State Fund policyholders can use the materials below to
User ID
meet those obligations. The chart below lists the mandated materials and when
employers should distribute them.
Password

Individual Form Links

You can view and download each individual form by clicking on the link(s) below.
Forgot Password?

Policy Time of Time of Why Register?

Required Materials
Inception Hire Injury Register Now

Notice to Employees DWC 7 (Replaces State Fund Forms e13708 and

e13709, English & Spanish)

Notice to Employees DWC7 Must be posted at every worksite in a

location that is easily visible to your employees. Must be posted in both

English and Spanish where there are Spanish-speaking employees.

Before posting the notice, enter the following information below:

MPN Website: http://www.statefundca.com/mpn MPN Effective Date:

02/01/2016

MPN Identification Number: 2432

MPN Access Assistant: (855) 521-7082; Fax Number: (571) 446-2070

MPN Contact Person: (888) 626-1737

Claims Administrator: State Compensation Insurance Fund; Phone: 1

(888)-782-8338

Workers’ compensation insurance carrier: State Compensation Insurance

Fund

DWC’s Information & Assistance Office: www.dir.ca.gov/dwc/ianda.html

Employee’s Guide to The State Fund MPN by Harbor Health e3851

(Replaces State Fund form e13176, English & Spanish)

Must be provided to employee at time of injury or, where there is

existing injury, and when transferring care into the MPN. Must be

provided in both English and Spanish if the employee primarily speaks

Spanish.

New Employee’s Guide to Workers’ Compensation e13286

Workers’ Compensation Claim Form e3301 with instructions

Employer’s Report of Occupational Injury or Illness e3067

Must be completed and submitted to State Fund no later than 5 days

from the date of knowledge of a work injury or illness.

PENALTIES
Per Title 8 California Code of Regulations (CCR) section § 9881 all California Employers
are required to display this poster at every worksite in a location that is easily visible to
your employees. Must be posted in both English and Spanish where there are Spanish-
speaking employees. Non-compliant employers face potential penalties up to $7,000.00.

Claims Kit
For your convenience, we’ve grouped the forms needed to report a claim into a single
downloadable Claims Kit (PDF).

Call Us
If you have additional questions, please call our Customer Service Center at 888-
STATEFUND (888-782-8338).

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20/2/2018 Forms

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