QUICK ACCESS: Workers’ compensation claim form DWC 1
Workers’ compensation is a state-mandated program for employees who become injured or ill in the course of their employment. All employees are automatically eligible the first day of employment, as are registered volunteers. (Contractors and temporary agency employees are not covered under USC’s workers’ compensation.) USC’s workers’ comp claims are handled and paid directly by Broadspire, a third party administrator.
The Worker’s Compensation Policy was designed by the university to provide all eligible individuals with information and a clear understanding of federal and state regulations, guidelines, and reporting requirements when filing a workers’ compensation claim.
The Workers’ Compensation and Disability Department is committed to the advocacy and support of our faculty and staff through our program and are excited to share a new resource: Workplace Injury and Illness Infographics for supervisors and employees.
These infographics are designed to provide individuals with essential information at a glance. You can clearly identify what steps to take in the event of a workplace injury, along with information on whom to contact with further questions.
- Life threatening emergency related to a workplace incident
- Non-emergency injury related to a workplace incident
- Repetitive stress related to my job
- Mental health situation related to my job
- Emergencia que amenaza la vida relacionada con un accidente en el lugar de trabajo
- Lesión que no es de emergencia relacionada con un incidente en el lugar de trabajo
- Lesión por estrés repetitivo relacionada con mi trabajo
- Mental relacionada con mi trabajo
- A member of my staff has been injured on the job
- A member of my staff has been injured on the job and refuses treatment
- A member of my staff is injured but has not lost time from work
If you are eligible for benefits, there is a 3-day waiting period (including weekends) before payments begin, starting from the first full day you are unable to work (you should be paid for the day of the injury). You can use sick or vacation time, or a combination of both, to cover the waiting period – but if you do not have enough accrued, you will be on leave without pay for whatever portion of the 3-day waiting period is not covered. Note that you do not have to fulfill the 3-day waiting period if you are off work for 14 days or more for your injury, or if you are immediately hospitalized.
In order for an injury or illness to be considered work-related it must arise out of and occur in the course and scope of employment. Injuries or illnesses originating outside the scope of employment are not covered, nor is injury resulting from horseplay or USC policy violations. In addition, if an injury claim is made after an employee has been terminated and there is no medical evidence the injury occurred prior to termination, it is not covered.
- Medical care: You must be medically certified by a physician within the USC Medical Provider Network (USC MPN) to be eligible for benefits, and all medical bills will be paid by the university. If you decide to treat with a provider outside the USC MPN, the university is not required to pay for the treatment—this includes treatment by any doctor (including a USC doctor) who is not an authorized MPN physician.
- Temporary disability benefits: Payments if you lose wages because your injury prevents you from doing your usual job while recovering.
- If missing time from work, you must also file a disability claim with Broadspire. The disability must run concurrently with your workers' comp claim. Disability payments, if applicable, will be coordinated/offset with workers' comp payments. NOTE: If you are not receiving disability pay or if disability payments are not sufficient to pay benefit premiums, you must make arrangements to continue paying your benefit premiums. If arrangements are not made coverage is cancelled after 60 days of nonpayment. If coverage is cancelled due to nonpayment, the employee will no be eligible for COBRA, and will need to visit www.healthcare.gov or call (800) 318-2596 (24/7 access) to review options available through the Affordable Care Act.
- Permanent disability benefits: Payments if you don't recover completely.
- Supplemental job displacement benefits (if your date of injury is in 2004 or later): Vouchers to help pay for retraining or skill enhancement if you don't recover completely and don't return to work for your employer.
- Death benefits: Payments to your spouse, children or other dependents if you die from a job injury or illness.
#1 - Immediately report any workplace injury or illness to your supervisor/HR Partner.
#2 - Contact USC's workers' compensation administrator, Broadspire, by calling (800) 495-2315 (answered 24/7).
- You will be "triaged" to a specially-trained nurse who will immediately assess the injury and determine the best course of action for you. Nurses have access to interpreters to help with over 200 languages when necessary. Depending on the situation, you may be guided in first aid (self-care), allowed back to work, or be referred to a medical facility within the USC Medical Provider Network for further evaluation.
- Contacting Broadspire is crucial because this is how you obtain a claim number allowing you to seek medical treatment. If you are unable to call, the HR Partner must call Broadspire.
- NOTE: there is no claim unless the employee or HR Partner notifies Broadspire.
#3 - Submit completed workers' compensation claim form DWC-1 to your supervisor or HR Partner.
- The employee must complete the top portion of DWC-1 form and include Social Security number and original signature (see sample DWC-1 form).
- Employees who seek medical treatment and/or wish to file a claim must complete this form within 24 hours of sustaining the injury.
- State law requires USC to authorize medical treatment within one working day of receiving the completed form.
- If you delay reporting your injury or completing the form, it may delay benefits or jeopardize your right to obtain benefits altogether.
#4 - Provide work status updates to your HR Partner and Broadspire after each medical appointment. Documentation is important in determining the ability to return to work or accommodation.
For serious injury/illness
If a serious injury has occurred call the following DPS number based on your location (DPS will contact paramedics and send personnel to the injured worker):
- UPC - (213) 740-4321
- HSC - (323) 442-1000
- USC-VHH - (818) 952-4444
If an employee is admitted to a hospital, the HR Partner must immediately notify the HR Service Center at (213) 821-8100 and USC Environmental Health and Safety at (323) 442-2200 as per OSHA regulations.
For non-life-threatening injuries
USC coordinates treatment with several medical facilities. If you're injured during the workweek 8:30am – 4pm, you can receive immediate treatment at the following medical facilities listed in the Worker's compensation medical facilities tab below.
When an employee in your department is injured on the job, you must fulfill three responsibilities:
#1 - Find out what happened - you are our first line of defense.
- Investigate incidents thoroughly
- Take statements from the injured worker and any witnesses to find out how the accident occurred
- Follow up to ensure any unsafe conditions are corrected to prevent future occurrences
- If an injury seems questionable, email firstname.lastname@example.org
#2 - Instruct employee to contact USC's workers' compensation administrator, Broadspire, by calling (800) 495-2315 (answered 24/7).
- The employee will be "triaged" to a specially trained nurse who will immediately assess the injury and determine the best course of action. Nurses have access to interpreters to help with over 200 languages when necessary. Depending on the situation, the employee may be guided in first aid (self-care), allowed back to work, or be referred to a medical facility within the USC Medical Provider Network for further evaluation.
- Contacting Broadspire is crucial because this is how employees obtain a claim number allowing them to seek medical treatment.
- If the employee is unable to call, the HR Partner must call Broadspire.
- NOTE: there is no claim unless the employee or HR Partner notifies Broadspire.
- If employee declines medical treatment, the DWC-1 form is not required.
- If employee seeks medical care, the employee must complete the top portion of DWC-1 form and must include Social Security number and original signature. Managers are responsible for completing the bottom portion of the form (see sample DWC-1 form).
- Managers must provide this form to the employee on the same day the employee notifies them of an injury or illness.
- Both forms should be sent to your HR representative and to USC Workers’ Compensation via the HR Service Center at email@example.com.
Note that the employee must provide a work status after each medical visit.
- For employees unable to return to their usual and customary job duties:
- Conduct and document interactive process
- Notify workers’ compensation/disability coordinators immediately to prevent delay in benefits
- For employees able to be accommodated with physical or hourly restrictions:
- Complete the temporary modified duty agreement form
- Provide a copy to USC workers’ compensation via the HR Service Center at firstname.lastname@example.org.
- Communicate any updates in medical work status to workers’ compensation/disability coordinators up to discharge.
USC Internal Medicine (HSC)
1520 San Pablo St, Ste. 1000
Los Angeles, CA 90033
1526 North Edgemont St, 1st Floor
Los Angeles, CA 90027
ProActive Work Health Services
132 Beaudry Avenue
Los Angeles, CA 90012
(open 24 hours/7 days week; free shuttle for first visit)
If you are injured during the workweek after 4pm or on the weekend, you can receive immediate treatment at the following facilities:
ProActive Work Health Services
132 Beaudry Avenue
Los Angeles, CA 90012
(open 24/7;free shuttle for first visit)
Bank of America Plaza
333 S Hope St, Suite C130
Los Angeles, CA 90071
Good Samaritan Hospital Emergency Room
1225 Wilshire Blvd
Los Angeles, CA 90017
USC Verdugo Hills Hospital
1812 Verdugo Blvd
Glendale, CA 91208
If you are injured at a USC work facility offsite, you may seek medical care at the nearest emergency room. Once you complete the workers' compensation claim form DWC 1 and contact Broadspire to initiate a claim by calling (800) 495-2315, Broadspire will help you locate a facility that is part of the USC Medical Provider Network - see next tab.
After initial treatment, you may continue treatment with the initial medical provider, or you may choose another physician in the USC MPN. The USC MPN is a group of state-approved health care providers, with expertise in general areas of medicine, who provide medical treatment to USC employees who have been injured or become ill while working. Please note that specialty care or diagnostic testing both require referral from your MPN treating physician, and authorization from Broadspire. (Only those who have pre-designated a physician before the injury/illness occurred may treat outside the MPN - see below.)
To find an MPN provider:
- Contact an MPN Medical Access Assistant, Mon-Sat, 7am-8pm Pacific, toll-free at (844) 752-1143; fax (855) 279-2518, or BroadspireMAA@anthemwc.com.
- Look up providers yourself at https://www.viiad.com/anthemcompass/KBANTHEMW000.
- Contact USC workers' compensation staff through the HR Service Center at (213) 821-8100.
California law allows employees to pre-designate a personal medical doctor (MD) or doctor of osteopathic medicine (DO) to treat them, in the event of a work-related injury or illness if:
- the employer offers group health coverage;
- the doctor is the employee's regular physician (either a physician who has limited his or her practice of medicine to general practice or who is a board-certified or board-eligible internist, pediatrician, obstetrician-gynecologist, or family practitioner), has previously directed the employee's medical treatment, and retains the employee's medical records;
- prior to the injury the employee's doctor agrees to treat the employee for work injuries or illnesses; and
- prior to the injury, the employee provides USC a Pre-designation of personal physician form which indicates the employee wishes to treat with his/her own personal physician instead of an MPN doctor.
If you wish to pre-designate a physician, please provide the completed form to your HR Partner, any time before the date of an injury.
Your HR Partner will provide you with the Pharmacy First Fill Information form, which is a temporary pharmacy ID card, so that you will have no out-of-pocket expense for your first prescriptions. This card is only valid for the first 30 days of a new injury that requires medication, and is limited to a maximum 14-day supply up to $300. After your workers' compensation claim is accepted, you'll receive a Broadspire Health Ticket with pharmacy ID card via U.S. mail. The Health Ticket will list the claim number in the prescription drug ID card section (upper left corner), as well as the phone number to contact the adjuster.
USC's Return-to-Work program is designed to benefit injured employees and their departments by promoting rapid recovery, providing a safe and timely transition back to work, and maintaining productivity in the workplace.
Employees whose medical condition temporarily prevents them from performing their full regular duties are automatically included in the program when their treating physician has:
- Certified that the employee has a temporary condition
- Determined the employee's current physical capacities
- Released the employee to return to work with physical or hourly restrictions
- Estimated the recovery period
If the employee has been released to return to work with physical or hourly restrictions, their HR Partner will assess whether the employee can be accommodated based on the restrictions.
- If the restrictions can be accommodated: The employee will be placed on modified duty in their regular job. Their HR Partner will provide return to work assignments, in writing and for each medical visit that produces a new work status with restrictions, until the employee is discharged from medical care and released to full duty.
- If the restrictions cannot be accommodated and an employee is not capable of performing their usual and customary duties: Their HR Partner will work with the Return-to-Work Coordinator from the University HR Workers’ Compensation team to further assess employee’s capabilities for accommodation.
Benefits of the Return-to-Work program:
- Employee will experience a smoother transition back to regular duty
- Employee will maintain relationships with co-workers and management
- Supports employee’s well-being, financial security, and quality of life
If you have any questions, please contact the HR Service Center by email at email@example.com or call 213-821-8100. More information can be found in the Return-to-Work section of the Unpaid Accommodated Medical Leave policy.
The new online training for Workers’ Compensation and Disability is now available via TrojanLearn. This training is mandatory for all HR Partners and available to all managers, supervisors, staff, and faculty.
Plan Administrator, Broadspire | https://myclaim.choosebroadspire.com
All disability and workers' compensation questions can be directed to Broadspire, which also offers online and mobile access.
USC Disability Management (via the USC HR Service Center) firstname.lastname@example.org or (213) 821-8100
Workers' compensation claim form DWC 1
Covered Employee Notification of Rights ENGLISH and SPANISH
Facts about workers' compensation
Manager incident report
Volunteer injury or illness report
Pre-designation of personal physician
Declination of workers' compensation
Note: Workers’ compensation fraud is a crime!
The cost of workers’ compensation fraud is handed down to everyone. It affects our business operations, employee job security and wages, and has become a growing concern for many organizations. As such, we have taken measure to deter any possible fraudulent claims. Making a false statement or representation to obtain a workers’ compensation benefit payment is grounds for termination and criminal prosecution. Anyone who makes or causes to be made a knowingly false or fraudulent statement in order to obtain or deny workers’ compensation benefits or payments is guilty of a felony, and if convicted will pay fines of up to $50,000 and/or serve up to five years in jail.