COVID-19 Employer Reporting Form for Outbreak Determination (California SB-1159)
Important Notice: On 9/17/2020 California enacted SB-1159 which imposes certain reporting requirements on California employers. Effective immediately, employers are required to report positive COVID-19 tests to their workers compensation claim administrator, whether there is an allegation the COVID-19 exposure is related to work or not. According to the legislation, an employer who intentionally submits false or misleading information, or fails to submit information when reporting, could be subject to a civil penalty in the amount of up to $10,000, to be assessed by the Labor Commissioner. Additional information can be found HERE.
 
Note:
 
  • If you have more than one employee who has tested positive for COVID-19, you must complete a separate form for each
  • If the employee is not claiming the exposure is work related, do not include any personally identifiable information (e.g. – name, SSN, etc.)
  • If the employee is claiming the exposure is work related or has filed a DWC-1, you’ll need to report the workers compensation claim to AmTrust in addition to completing this form:
24/7 Toll-Free Claim Reporting for ALL States
Phone: (866) 272-9267
Fax: (775) 908-3724 or (877) 669-9140
Email: amtrustclaims@qrm-inc.com

 

*Required Fields

Who is this report for?:

  • Please select an option
  • Please enter a Name.
  • Please enter a vaild Policy Number
  • Please enter a vaild Street Address
  • Please enter an City
  • Please enter an State
  • Please enter a valid Zip Code

Have any of the locations the employee has worked in been ordered closed by a local heath department, the State Department of Public Health, the Division of Occupational Safety & Health, a school superintendent, etc. due to the risk of infection by COVID-19


  • Please select an option

Date field is only required if YES is selected in prior question.

Has or will a workers compensation claim be filed as a result of this COVID-19 exposure?


  • Please select a value.

COVID-19 Test Date (Date Test Sample Taken)

 

Date Employee Last Worked Before Positive COVID-19 Test Taken

Physical Work Site Information

(Provide information for all work sites the infected employee worked at in the 14 days prior to the test date.)

  • Please enter a location
  • Please enter the number of employees
  • Please enter an Name
  • Please enter a Title
  • Please enter a valid email.
  • Please enter a Phone Number

Date Completed:

 

 

If you experience any issues while submitting the form please contact us at COVID@amtrustgroup.com.

Please be advised that we have gathered information relevant to COVID-19 and its impact to worker’s compensation claims and your businesses. These materials do not constitute legal advice, nor should any of the information that we provide be construed as legal advice. Furthermore, the information we have provided does not include all relevant information and should not be used as the basis for legal, claim benefit safety, or human-resource-related decisions. Please seek legal advice from an attorney with expertise in the relevant subject areas and state law in regard to whether a COVID-19 related claim is compensable under a specific state’s law.

Time Zones

13

Countries

34

Brands

12

Agents

9500