10-100.M.  Accident Procedures  


Table of Contents

The Accident Procedures section includes the following information:





Workers’ Compensation


Accident Procedures




Claims Adjusters


CPG Letter 319 (3/14)

ACL No. 13-56


Workers’ Compensat-ion

Workers’ Compensation is covered by the State of California through the California Department of Social Services (CDSS), for individuals injured while participating in CalWORKs WTW activities including the following:


·         Unpaid Work Experience

·         Unpaid Community Service

·         Subsidized Employment


Note:  The CDSS Workers’ Compensation contract only covers subsidized employment when a County Welfare Department (CWD) is the employer of record.  If any other entity, including other government agencies (e.g. workforce investment board), is the employer of record, that employer must provide the Workers’ Compensation coverage.



Accident Procedures

The accident procedures outlined in this section are mandatory and cannot be modified.


If a WEX participant is injured at a Work Site the participant is covered by Workers’ Compensation Insurance through self-insurance by CDSS.  The current Insurance carrier is York Risk Services Group, Inc.  When notification of an accident or injury occurring at a Work Site is received, the WEX Coordinator and/or the ECM Supervisor or other designated staff shall follow the procedures outlined in this section within one (1) working day. 


The Regional Representative shall:





Instruct the Work Site Supervisor to send the participant to the nearest authorized Care Provider.  To identify authorized Care Providers access the State Compensation Insurance Fund Medical Provider Link:





Within 24 hours of the accident/injury:

·   The participant and the Work Site Representative/ ECM/County contact representative must complete the Workers’ Compensation Claim Form (DWC 1).

·   If the participant is unavailable at the Work Site, the ECM shall attempt to deliver the form to the participant at the location of the medical provider. 

·   If the participant is not available at either the Work Site or the medical provider, the ECM shall make a home visit in order to have the participant complete the form. 


Complete lines 9-17 of the DWC 1 and give the form to the employee/participant to sign. See DWC 1 instructions below.


Have the employee sign and date the Acknowledge of Receipt of the Workers’ Compensation Claim Form (line 8).


Give the employee a copy of the DWC 1 and the cover sheet after they sign the DWC 1 form.


Complete the Employer’s Report of Occupational Injury or Illness, Form 5020.  All information requested on the Form 5020 is essential for the proper handling of the potential claim.  To access the form online click on the following York link at York Risk Services Group, Inc..  The information provided on Form 5020 must be complete, and contain the worksite supervisor’s signature and title.


Note: The worksite supervisor’s signature is not an admission of liability.


Form 5020 can be filed with York via online, fax, and mail.


Complete the Reporting Package to include:

·         DWC 1

·         Form 2050

·         Verification of the Work Experience Referral/Activity Assignment (27-301 HHSA)

·         Any Medical Reports and/or Medical Bills

·         The Amount of Maximum Aid:

o   Include Grant amount for the previous 12 months.  This information is used to determine the correct disability amounts.


Note: The Regional Representative’s Supervisor shall review the Reporting Package for accuracy. 


The Employer/Worksite Supervisor/county contact representative should retain a copy for their records and forward the packet to the WEX Program Specialist.


The WEX Program Specialist will sign the DWC 1 on behalf of the County of San Diego and fax the Reporting Package to:


York Risk Services Group

P.O. Box 619058

Roseville, CA 95661

Ph. No.: (855) 446-9675

Fax No.: (866) 548-2637


ACL No. 13-56



The ECM will assist the employee/WEX participant in completing the Workers’ Compensation Claim Form (DWC 1) lines 1-7 and have them sign on line 8.  The ECM will list the County of San Diego – CalWORKs Program on line 9 and line 10 will list the Eligibility Operations address at 1255 Imperial Avenue, Ste. 446, San Diego, CA 92101.  The name and address for the insurance carrier on line 14 should list:


York Risk Services Group, Inc.

Box 619079

Roseville, CA 95661-9079


For the Insurance Policy Number on line 15 list “CalWORKs”.



Claims Adjusters

Claims adjusters will be contacting the WTW County Coordinators for further information on individual cases.  It is the responsibility of the WTW Coordinators to provide the necessary information to the York claims examiners or adjusters. 


Cooperating with the adjusters and providing the requested information is not considered a violation of confidentiality since York is under contract with CDSS to administer the benefits and is acting on behalf of CDSS. 


York Risk Services adjusters may ask questions regarding:


·   Return to work dates

·   Length of WTW assignment

·   Availability of alternative/modified work

·   Background information

·   Medical information; and

·   Grant information