notice to employees
IF a work injury occurs
California law guarantees certain benefits to employees who are injured or become ill because of their jobs.
Any job related injury or illness is covered. Types of injuries and illnesses covered includes, but may not be limited to,
strains, sprains, cuts, cumulative or repetitive fractures, illnesses and aggravations. Some injuries from voluntary, off
duty, recreational, social or athletic activity may not be covered. Check with your supervisor or claims administrator if
you have questions.
All work related injuries must be reported to your supervisor immediately. If you wait too long, you may lose your
right to benefits. Your employer is required to provide you a claim form within one working day after learning about
your injury.
It is a misdemeanor for an employer to discriminate against workers who are injured on the job or who testify in another
employee’s case. Any such employee may be entitled to compensation, reinstatement and reimbursement for lost wages
and benefits.
Workers Compensation Benefits include
MEDICAL CARE - All medical treatment - without a deductible or dollar limit. Within one working day after
you file a claim form, treatment must be authorized, consistent with the applicable treating guidelines, for
your alleged injury up to ten thousand dollars ($10,000) until the claim has been accepted or rejected. Costs
are paid directly by the claim administrator, so you should never see a bill. For dates of injury on or
after1/1/04 there is a limit on some medical treatment.
You may be eligible to treat with your personal physician should you become injured on the job. If eligible, you must
notify your employer in writing before you are injured. If you have questions please contact your employer who is
required to provide written information regarding workers’ compensation benefits to all new employees.
MEDICAL PROVIDER NETWORKS - Your employer may be using an MPN, which is a selected network of healthcare
providers to provide treatment to workers injured on the job. If you have predesginated a personal physician prior to
your work injury, then you may receive treatment from your predesignated doctor. If you have not predesignated and
your employer is using an MPN, you are free to choose an appropriate provider from the MPN list. If you are treating
with an non-MPN doctor for an existing injury, you may be required to change to a doctor within the MPN.
PAYMENT FOR LOST WAGES - If you’re temporarily disabled by a job injury or illness, you’ll receive tax-free income,
subject to state limits, until your doctor says you are able to return to work. Payments are two-thirds of your average
weekly pay, up to a maximum set by state law. Payments aren’t made for the first three days unless you’re hospitalized
as an inpatient or unable to work more than 14 days.
If the injury or illness results in permanent disability, additional payments will be made after recovery. If the injury
results in death, benefits will be paid to surviving dependents.
SUPPLEMENTAL JOB DISPLACEMENT BENEFIT - You may be entitled to a Supplemental Job Displacement Voucher, if
your employer is not able to return you to work within 60 days after temporary disability ends. SJDB is a nontransferrable
voucher payable to a state approved school.
In the event of a work injury
1. Be sure first aid is given.
2. If emergency medical treatment is needed call 911.
3. See that the injured employee is taken to a doctor or hospital, if necessary.
4. Report all injuries immediately to your supervisor or TARANJIT CHAHAL at (530) 741-6979 Employer Representative Phone Number
5. Contact your employer representative or claim administrator if you have questions about workers’ compensation. You may also contact an
Information and Assistance Officer at the State Division of Workers’ Compensation at 1(800) 736-7401 or (916) 928-3158
6. Hear recorded information and a list of local offices by calling toll-free 800 736-7401 or visit www.dir.ca.gov
Claims Administerd by: Emergency Numbers:
Claims Administrator: Keenan & Associates Ambulance: 911
Address: 2882 Prospect Park Drive, Suite 200 Fire Department: 911
City, State, Zip Code: Rancho Cordova, CA 95670 Police: 911
Phone Number: (916)859-7160 Hospital 911
Carrier/Self Insured: Northern Ca Comm Colleges Self Insur. Athority (NCCC-SIA)-PIPS
Policy expiration date: Yearly renewal each July 1st - If this policy has expired contact the labor commissioner (213) 620-6630
MPN Toll Free Number: 1(800) 654-8102
MPN Website: www.Keenan.com
MPN Effective Date: N/A
MPN's Address: P.O. Box 4328, Torrance, CA 90510
Anyone who knowingly files or assists in the filing of a false workers’ compensation claim may be fined up to $150,000 and sent to prison for up to five years. (Insurance Code Section 1871.4)
If a work injury occurs
Workers’ Compensation Benefits include
In the event of a work injury
Claims Administered by: Emergency numbers: