COVID-19 Employer Reporting Form (CA SB-1159)

COVID-19 Employer Reporting Form for Outbreak Determination (California SB-1159)

Important Notice: On September 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: (888) 239-3909
Email: workerscompclaimreport@amtrustgroup.com
Online: amtrustfinancial.com/login

*Required Fields

Who is this report for?:

COVID-19 exposure on or after 9/17/2020 (must be reported within 3 days of knowledge of exposure)
COVID-19 exposure from 7/6/2020 through 9/16/2020 (must be reported by 10/27/2020)

Please select an option

Insured Name:

Please enter a Name.

Insureds Policy Number:

Please enter a vaild Policy Number

Street Address:

Please enter a vaild Street Address

City:

Please enter an City

Please enter an State

Zip Code:

Please enter a valid Zip Code

Employee ID (Not Employee's Social Security Number):

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

Yes
No

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?

Yes
No

Please select a value.

COVID-19 Test Date (Date Test Sample Taken)

Date Employee Last Worked Before Positive COVID-19 Test Taken

Optional Office Code if available

Office Code:

Physical Work Site Information

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

Work Site Location #1 Name and Address:

Please enter a location

Maximum Number of Employees At This Location in the 45 Days Prior to the Last Day Employee Was At Work Site #1:

Please enter the number of employees

Work Site Location #2 Name and Address:

Maximum Number of Employees At This Location in the 45 Days Prior to the Last Day Employee Was At Work Site #2:

Work Site Location #3 Name and Address:

Maximum Number of Employees At This Location in the 45 Days Prior to the Last Day Employee Was At Work Site #3:

Work Site Location #4 Name and Address:

Maximum Number of Employees At This Location in the 45 Days Prior to the Last Day Employee Was At Work Site #4:

Work Site Location #5 Name and Address:

Maximum Number of Employees At This Location in the 45 Days Prior to the Last Day Employee Was At Work Site #5:

Work Site Location #6 Name and Address:

Maximum Number of Employees At This Location in the 45 Days Prior to the Last Day Employee Was At Work Site #6:

Work Site Location #7 Name and Address:

Maximum Number of Employees At This Location in the 45 Days Prior to the Last Day Employee Was At Work Site #7:

Work Site Location #8 Name and Address:

Maximum Number of Employees At This Location in the 45 Days Prior to the Last Day Employee Was At Work Site #8:

Work Site Location #9 Name and Address:

Maximum Number of Employees At This Location in the 45 Days Prior to the Last Day Employee Was At Work Site #9:

Work Site Location #10 Name and Address:

Maximum Number of Employees At This Location in the 45 Days Prior to the Last Day Employee Was At Work Site #10:

Add More Work Sites

Completed By:

Please enter an Name

Title:

Please enter a Title

Contact Email:

Please enter a valid email.

Contact Phone:

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.