1. 1. Employer Information.

   Name:

   FEIN:

   Principal business of employer (please circle one or more):

   3201.5:

   construction construction maintenance rock, sand, gravel, cement and asphalt operations heavy-duty mechanics surveying construction inspection

   3201.7:

   education and health services financial activities government information leisure and hospitality manufacturing natural resources and mining professional and business services transportation and utilities wholesale and retail trade other (specify)

2. 2. Name of union participating in the Section 3201.5 or 3201.7 agreement:

3. 3. Dates that the Section 3201.5 or 3201.7 provision was in effect during the previous calendar year:

   Beginning date:

   Ending date:

4. 4. Name of insurer:

5. 5. Insurance policy number:

   5a. If an employer is legally self-insured under authority of the Department of Industrial Relations' Office of Self-Insurance Plans, list certificate number and name:

6. 6. Attach payroll in accordance with the rules of the Workers' Compensation Insurance Rating Bureau (WCIRB). Payroll shall be reported by class code as set by the WCIRB and provided in table format.

7. 7. Total person hours worked by covered employees, indicate by trade or craft:

   Trade:

   Person Hours:

   Trade:

   Person Hours:

   Trade:

   Person Hours:

   (Note: If there are more trades represented, attach additional sheets with the required information on person hours worked.)

   DWC Form GV-2 (012004)

   Questions 8 through 27 apply to claims filed in the previous calendar year pursuant to Labor Code §§ 5401 or 5402. For claims with a date of injury on or after January 1, 2003, the information reported shall be for the year in which the claim was filed, and the subsequent calendar years until the claim is resolved. However, information from no more than four calendar years (including the year the claim was filed) shall be reported on each claim.

8. 8. Number of claims that were medical only:
9. 9. Total amount of paid costs for medical only claims:
10. 10. Total amount of incurred costs for medical only claims:
11. 11. Number of claims that included a claim for indemnity:
12. 12. Total amount of paid temporary disability for indemnity claims:
13. 13. Total amount of incurred temporary disability for indemnity claims:
14. 14. Total amount of paid permanent disability for indemnity claims:
15. 15. Total amount of incurred permanent disability for indemnity claims:
16. 16. Total amount of paid life pensions for indemnity claims:
17. 17. Total amount of incurred life pensions for indemnity claims:
18. 18. Total amount of paid death benefits for indemnity claims:
19. 19. Total amount of incurred death benefits for indemnity claims:
20. 20. Total amount of paid vocational rehabilitation for indemnity claims:
21. 21. Total amount of incurred vocational rehabilitation for indemnity claims:
22. 22. Total amount of paid medical services for indemnity claims:
23. 23. Total amount of incurred medical services for indemnity claims:
24. 24. Total amount of paid medical legal expenses for indemnity claims:
25. 25. Total amount of incurred medical legal expenses for indemnity claims:
26. 26. Number of claims that were resolved (resolved means one in which ultimate liability has been determined, even though payments may be made beyond the reporting period):

27. 27. Number of claims that remained unresolved:

    Note: The numbers in questions 26 and 27 added together should equal the summation of the number of medical only claims (question 8) and indemnity claims (question 11).

28. 28. The number of claims that were resolved with a denial of compensability:
29. 29. The number of claims that were resolved before mediation:
30. 30. The number of claims that were resolved at or after mediation:

31. 31. The number of claims that were resolved at or after arbitration.

    Note: For employers who utilize a alternative dispute resolution system that includes resolution procedures in addition to or in place of mediation and/or arbitration, please identify on an attachment each resolution procedure used and the number of claims that were resolved using that procedure.

32. 32. The number of claims that were resolved at or after the Workers' Compensation Appeals Board (WCAB):
33. 33. The number of claims that were resolved at or after the court of appeals:

34. 34. Provide the title and number of every application filed with the WCAB during the previous calendar year concerning the claim alleged by any party to fall within the Section 3201.5 or 3201.7 provision, regardless of whether the employee had the right to file such a application (example in italics):

    Title:

    Jane Doe vs. ABC Co

    Number:

    SFO 0123456

    Title:

    Number:

    Note: If there are more applications, attach additional sheets with the required information.

35. 35. Provide the title and court number of every civil action, including petitions for writs and injunctions in any court, state or federal, filed in the previous calendar year, that concerned a claim alleged by any party to fall within the Section 3201.5 or 3201.7 provision (example in italics):

    DWC Form GV-2 (012004)

    Title:

    Jane Doe vs. ABC Co

    Number:

    Alameda County No 3 76052

    Title:

    Number:

    Note: If there are more civil actions, attach additional sheets with the required information.

36. 36. The number of injuries and illnesses reported in the previous calendar year on the United States Department of Labor OSHA Form No. 300 for those employees covered by the Section 3201.5 or 3201.7 provision:
37. 37. The number of employees covered by the Section 3201.5 or 3201.7 provision who participated in vocational rehabilitation:
38. 38. The number of employees covered by the Section 3201.5 or 3201.7 provision who participated in a light duty program or modified return to work programs established under Section 3201.5 or 3201.7:
39. 39. For an employer who is covered by a 3201.7 provision, please provide an employee survey that measures worker satisfaction with the applicable 3201.7 alternative dispute resolution procedures. The survey shall be designed and administered by agreement between the employer and the union.

40. 40. Please attach any explanatory material, narrative account or comment that you believe would enable the Division to understand your response(s).

    Programs are encouraged to submit updated information covering prior calendar year claims reported to Division of Workers' Compensation.

    DWC Form GV-2 (012004)

STATE OF CALIFORNIA

Department of Industrial Relations

Division of Workers' Compensation

Administrative Director

Post Office Box 420603

San Francisco, CA 94142

Telephone: (415) 703-4600

Individual Employer Annual Report

Labor Code §§ 3201.5 and 3201.7; Title 8, California Code of Regulations § 10203

For the 12 month period ending December 31, 20__.

The following information is being obtained by the Administrative Director pursuant to Labor Code §§ 3201.5 and 3201.7, and Title 8, California Code of Regulations Section 10203. An individual employer who is participating in a Section 3201.5 or 3201.7 program with a group of employers shall provide the information requested in this form to the administrator of the Section 3201.5 or 3201.7 program, or the contact person or persons identified in Title 8, California Code of Regulations § 10201(a)(1)(D) and (2)(B) or § 10202(d)(1)(C) or (2)(B). The information provided to the program shall be confidential and not subject to public disclosure under any law of this state. However, the Division of Workers' Compensation may create derivative works based on collective bargaining agreements and data. Those derivative works shall not be confidential, but shall be public. The information provided by the employer shall be maintained by the administrator of the program and is available for inspection by the Administrative Director upon reasonable written request.

Name of Program:

Statute Authorizing Program (circle one): 3201.5 -- Construction 3201.7 -- Other

Note: Authority cited: Sections 133 and 5307.3, Labor Code. Reference: Sections 3201.5, 3201.7 and 3201.9, Labor Code.

History

1. New section filed 4-22-2004 as an emergency; operative 4-22-2004 (Register 2004, No. 17). A Certificate of Compliance must be transmitted to OAL by 8-20-2004 or emergency language will be repealed by operation of law on the following day.

2. Certificate of Compliance as to 4-22-2004 order, including further amendment of section, transmitted to OAL 8-20-2004 and filed 10-4-2004 (Register 2004, No. 41).