Your Workers’ Comp Kit
Below are the forms you will need with workers’ comp info. Please download and fill out these forms and send them back to us.
Workers’ Compensation Instructions
This is an outline for what to do in the case of a workers’ compensation situation.
Zurich - CA MPN Employee Notice (English)
This PDF includes important info about medical care if you have an employee with a work related injury or illness.
Out of the Box - Workers’ Comp Clinics
A list of OOTB accepted clinics in San Francisco, South San Francisco and East Bay
Workers’ Compensation Claim Form (DWC 1) & Notice of Potential Eligibility. This is the claim form employees will use should they be injured or in the workplace.
Refusal to Treat
This form is used when an employee refuses medical treatment. It states that ModernHR/ Out of the Box Productions offered an employee Workers’ Compensation medical attention and authorization for treatment and asks the employee to sign that they decline medical services at this time.
Generic Authorization to Treat
This Modern HR form that gives authorization to treat.
This form is an acknowledgement what workers’ comp claim form (DWC-1) was received.
Supervisor’s Report of Injury
This is a form for you to report the injury of an employee.