How to file a Workers' Compensation claim
- Download the Employee's Claim for Workers' Compensation benefits and read all of the instructions at the top of the form.
- Complete only the "Employee" section of the form.
- Be sure to sign and date the claim form.
- Keep a copy of the claim form for your records.
- Return the claim form to your supervisor.
- Your supervisor should then complete the "Employer" section and forward the completed claim form to the workers compensation division.
- Obtain a copy of the completed claim form from your supervisor.
Generally, the claims administrator has fourteen days to mail you a status letter about your claim. If you don't receive this letter, you should contact a Workers' Compensation Division representative.
Electronic Payment Initiative
About the Electronic Payment Initiative
Electronic payment of disability and claim-related expenses from the Division of Workers’ Compensation began on August 1, 2019. All employees eligible to receive electronic payments were automatically enrolled at the time of implementation. For employees that are eligible to receive electronic payments, your benefits will be deposited into your net pay balance account (primary direct deposit account) currently on file with the Office of the Controller – Payroll Division. Based on your benefit schedule, electronic deposits will post every two weeks directly to your bank account. If you receive your regular pay through a US Bank Focus Pay Card, your existing card will be credited with your Workers’ Compensation benefit.
A paper remittance will not be provided to recipients of electronic payments. A payment listing may be provided upon request by contacting your assigned claims examiner. When electronic payments are issued to your bank account, the Workers’ Compensation Division sends information to be displayed next to the payment. This information may appear differently from one financial institution to another, as each institution chooses which information and in what format to display the remittance detail.
Opting Out of Electronic Payments
If you wish to opt out of electronic payments, or make changes to your payment preference after implementation, please complete and submit a Payment Preference form . Please note that the form must be signed with blue or black ink pen to be valid. If you recently received a notice regarding your eligibility to receive electronic payments, you do not need to submit a Payment Preference Form unless you wish to "opt-out" and continue to receive paper checks.
Updating Bank Account Information
The Workers’ Compensation Division cannot make any changes to your bank account information or provide information on any payroll-related matter. All bank account updates must be processed through the SF Employee Portal, or through your department’s payroll division. You must notify your department’s payroll division in advance of closing your bank account to avoid interruption of payments. When you change your primary bank account, there is a processing time period of up to fourteen days before Workers' Compensation receives the updated information. Changes to your bank account may result in your next scheduled benefit payment to be paid to your most recent bank account. Please contact your claims examiner for more information or to temporarily set your payment preference to a paper check to avoid disruption in your payments.
Electronic Payment Exclusions
Electronic payments are not available to employees who are separated, inactive or retired as of the date of program implementation; beneficiaries or dependents of a claimant; and employees of the Community College District.
Retirement & Separation
If you are eligible to receive electronic payments, and later retire or separate from your employment, you will continue to receive your benefit payments to the bank account that was on file at the time of your retirement or separation. Changes to your bank account upon retirement or separation cannot be processed, which may require transition from electronic payments to paper checks.
Medical Mileage Form
If you have to travel to get treatment for your work injury, you are entitled to re-payment of your travel costs. The mileage rate changes annually based on the Internal Revenue Service (IRS) published mileage reimbursement rate .
Mileage for reasonable travel to the pharmacy, parking, bridge tolls, public transportation and other travel related costs is included.
For mileage that occurs in 2022, the rate is 58.5 cents per mile. You may use this Medical Mileage Expense Form 2022 to claim your mileage or travel reimbursement by sending a completed copy to your claims examiner.
For mileage that occurs in 2021, the rate is 56.0 cents per mile. You may use this Medical Mileage Expense Form 2021 to claim your mileage or travel reimbursement by sending a completed copy to your claims examiner.
For mileage that occurs in 2020, the rate is 57.5 cents per mile. You may use this Medical Mileage Expense Form 2020 to claim your mileage or travel reimbursement by sending a completed copy to your claims examiner.