Claims Resources

This zip file contains all of the claims forms and reference documents for Employers and Employees in the state of California. Both English and Spanish versions are included in the kit.

Download Claims Kit

For Employees:

Injured employees need to complete the following forms:

• EE portion of the DWC-1 claim form
• Complete and Sign the Authorization to Release form
• Sign Fraud Statement form
• Complete the Pain Assessment and Body Diagram form

If you do not want to pursue a workers’ compensation claim, complete the Declination of Workers’ Compensation Benefits form.

For Employers:

An employer needs to complete the following forms for an injured employee:

• Employer’s First Report of Injury (Form 5020)
• Supervisor’s Accident Report form
• Employer portion of the DWC-1 once the EE has completed their portion (this is required), and if there are witnesses to the injury, secure written statements.

All forms should be emailed to CWclaims@corvel.com, faxed to (866) 774-1846, or mailed to P.O. Box 277550, Sacramento, CA 95827.

If you are severely injured, please visit your local hospital, urgent care, or known Point of Entry Clinic (POE). To speak to a nurse that can help address your injury please call (844) 326-2918.

Employers should report the claim to CWclaims@corvel.com, or call (844) 326-2918, provide the injured employee with a DWC-1 Claim Form, advise the injured worker of the POE Clinic, and complete the Supervisor’s Accident Report.

At the time of an incident, employees can call and speak with a registered nurse 24 hours a day, 7 days a week, who will evaluate the nature of the incident or injury and determine the employee’s immediate medical needs. To contact Telehealth, please call the Telehealth hotline at (844) 326-2918.

We are here to help. Call us at (916) 605-5202 or (916) 605-3860 and we can help you walk through the process.

Visit our Medical Provider Network (MPN) to find a doctor specialized with your type of work related injury.

Yes. There is a pharmacy ID card for you to provide to your pharmacy to ensure billing is done accurately. You can access your pharmacy ID card here or by calling Telehealth (844) 326-2918.

You can visit our general contact page that provides direct claims support contacts, or you can email us at CWclaims@corvel.com.

The ultimate goal is to get you healthy, well, and back to work. After submitting a claim, an adjuster will be assigned to your case. Once we receive all of the required documents, Care West’s Claims Unit will set up a claim and assign to a Claims Examiner who will contact you with claim information.

If you have a work related injury or illness and need more information about medical care, you can refer to the Work-Related Injury or Illness – Claim Overview document.