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Further Information

  • For the date of injury, it can either be a specific date (specific injury) or period of time (cumulative trauma). For example, if you have gradually developed back pain because of work duties and you recently took time off from work because the pain became unbearable, the period of injury will be the date you first noticed the pain until the last day you worked i.e. 10/19/2022 – 07/06/2023.

    This is called a cumulative trauma injury or CT for short.

  • Make sure to list all the body parts affected by the workplace injury. For example: neck, back, and both arms.

  • If your condition is not a physical injury, explain what the injury or illness is. For example, stress, depression, anxiety, COVID, cancer, loss of eyesight, hernia, burn, hearing loss, etc. If this does not apply please enter N/A.

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It is a felony for anyone to knowingly file a false or fraudulent workers’ compensation claim. The maximum fine for workers’ compensation fraud is $150,000, or twice the amount of the fraud, whichever is greater. (Insurance Code § 1871.4)


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