INSTRUCTIONS

1. CALL 1-877-682-7778 (toll free, 24 hours a day) to report the injury.

2. Complete the Incident Report Form * .

3. FAX THE COMPLETED FORM IMMEDIATELY TO THE WORKERS’ COMPENSATION OFFICE AT 805-893-8521. Give a copy to the employee, and retain a copy for your department file.

* The Incident Report form must be completed and submitted to the Workers’ Compensation Office within 24 hours of the University’s first notice of incident. It is the responsibility of the employee and supervisor (or department representative) to complete and submit this form to the Workers’ Compensation Office.

Click here to download the form in a modifiable PDF format.

FURTHER INFORMATION

If the employee’s injury or illness is medically determined to meet the State of California definition of injury as a workers’ compensation claim, the Workers’ Compensation Office will mail the employee a Workers’ Compensation Claim Form (DWC-1) with complete instructions.

Sedgwick CMS (Claims Management Services) has a contract with the University of California to administer the University’s workers' compensation claims. A Sedgwick CMS claims administrator will investigate the injury, and determine acceptance of the claim. If a representative from Sedgwick CMS contacts you, please provide any information requested. This includes departmental files, job description, or time records.

Reporting an injury or submission of a claim form does not imply automatic approval of the claim. Claims are approved by Sedgwick CMS for UCSB.

Please contact the Workers’ Compensation Office at 805-893-8050 for further information.

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