Get the free Workers' Compensation Carrier Request Form (CalPERS-0994) (PDF). CalPERS Forms

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State of California Public Employees Retirement System www.calpers.ca.govWorkers Compensation Carrier Request Section 1 You must complete the front side of this form, sign, date and forward to nonmember

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How to fill out workers compensation carrier request

01

Obtain the workers compensation carrier request form from your employer or the insurance company.

02

Fill out all required fields on the form, including your personal information, employer information, details of the injury or illness, and the date it occurred.

03

Attach any supporting documentation, such as medical records or incident reports, to the form.

04

Submit the completed form to the appropriate party, usually your employer's HR department or the insurance company.

Who needs workers compensation carrier request?

01

Employees who have suffered a work-related injury or illness and are seeking compensation for medical expenses and lost wages.

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What is workers compensation carrier request?

A workers compensation carrier request is a formal application made to an insurance company or carrier that provides workers' compensation insurance, seeking coverage or benefits for work-related injuries or illnesses.

Who is required to file workers compensation carrier request?

Typically, employers or their representatives are required to file a workers compensation carrier request to initiate the claims process for an injured employee.

How to fill out workers compensation carrier request?

To fill out a workers compensation carrier request, you need to provide detailed information about the injured employee, the nature of the injury, the circumstances surrounding it, and any relevant medical information or documentation.

What is the purpose of workers compensation carrier request?

The purpose of a workers compensation carrier request is to formally request benefits and coverage for an employee who has sustained a work-related injury or illness, ensuring they receive medical care and wage replacement as needed.

What information must be reported on workers compensation carrier request?

Information that must be reported includes the employee's personal details, the date and time of the injury, a description of the incident, details of medical treatment received, and any witnesses to the incident.

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