California Code of Regulations › Title 8 - Industrial Relations › Division 1 - Department of Industrial Relations › Chapter 4.5 - Division of Workers' Compensation › Subchapter 1.8 - Collective Bargaining Agreements Under Labor Code Sections 3201.5 and 3201.7 › Section 10203.1 - Aggregate Employer Annual Report (DWC Form GV-1)

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
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
Aggregate 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. This form shall be filed on
					 or before March 31 of every year by every employer or group of employers
					 participating in a "carve-out" program under Labor Code §§
										3201.5 or
					 3201.7. The
					 information provided on this form shall be for the 12 month period ending
					 December 31 of the previous calendar year. The information 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.
For groups of employers that have received an
					 above-referenced letter of eligibility, information obtained from individual
					 employers to provide the information required in this form shall be maintained
					 by 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) and
					 (2)(B). This information may be obtained
					 using the form entitled "Individual Employer Reporting Data" (DWC Form GV-2)
					 (Contained in Title 8, California Code of Regulations §
										10203.2.) Such information shall be
					 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
1. List
				  all employers with FEIN numbers (Federal Employers Identification Numbers)
				  doing business under the Section
				  3201. 5 or 3201.7 agreement. If you
				  need more space, use separate pages.
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)
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)
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)
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)
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. Name(s) of union(s) participating in the
				  Section 3201.5 or
				  3201.7 agreement:
3. Dates that the Section
				  3201.5 or
				  3201.7 provision was in effect
				  during the previous calendar year:
Beginning date:
Ending date:
4.
				  Name of insurer(s):
5. Insurance
				  policy number(s):
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. Name of administrator of
				  ADR system:
7. Address of
				  administrator:
8. Telephone number
				  of administrator: ( )
9. Name of
				  ombudsperson employed in an ADR system (if any):
10. Address of ombudsperson:
11. Telephone number of ombudsperson: ( )
(Note: If there is more than one ombudsperson, attach
					 additional sheets with the required information).
12. Name of mediator employed in an ADR
				  system (if any):
13. Address of
				  mediator:
14. Telephone number of
				  mediator: ( )
(Note: If there is more than one mediator, attach
					 additional sheets with the required information).
15. Name of arbitrator employed in an ADR
				  system (if any):
16. Address of
				  arbitrator:
17. Telephone number of
				  arbitrator: ( )
(Note: If there is more than one arbiter, attach additional
					 sheets with the required information).
18. Total person hours worked by covered
				  employees, indicate by trade or craft:
Trade:
Person Hours:
Trade:
Person Hours:
Trade:
Person Hours:
Trade:
Person Hours:
Trade:
Person Hours:
Trade:
Person Hours:
Trade:
Person Hours:
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.)
19. Attach payroll
				  for the employer(s) 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.
Questions 20 through 45 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.
20.
				  Number of claims that were medical only:
21. Total amount of paid costs for medical
				  only claims:
22. Total amount of
				  incurred costs for medical only claims:
23. Number of claims that included a claim
				  for indemnity:
24. Total amount of
				  paid temporary disability for indemnity claims:
25. Total amount of incurred temporary
				  disability for indemnity claims:
26. Total amount of paid permanent disability
				  for indemnity claims:
27. Total
				  amount of incurred permanent disability for indemnity claims:
28. Total amount of paid life pensions for
				  indemnity claims:
29. Total amount
				  of incurred life pensions for indemnity claims:
30. Total amount of paid death benefits for
				  indemnity claims:
31. Total amount
				  of incurred death benefits for indemnity claims:
32. Total amount of paid vocational
				  rehabilitation for indemnity claims:
33. Total amount of incurred vocational
				  rehabilitation for indemnity claims:
34. Total amount of paid medical services for
				  indemnity claims:
35. Total amount
				  of incurred medical services for indemnity claims:
36. Total amount of paid medical legal
				  expenses for indemnity claims:
37.
				  Total amount of incurred medical legal expenses for indemnity claims:
38. 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):
39. Number of claims that remained
				  unresolved:
Note: The numbers in questions 38 and 39 added together
					 should equal the summation of the number of medical only claims (question 20)
					 and indemnity claims (question 23).
40. The number of claims that were resolved
				  with a denial of compensability:
41. The number of claims that were resolved
				  before mediation:
42. The number of
				  claims that were resolved at or after mediation:
43. The number of claims that were resolved
				  at or after arbitration.
Note: For employers, or group of employers, who utilize an
					 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.
44. The number of claims that were resolved
				  at or after the Workers' Compensation Appeals Board (WCAB):
45. The number of claims that were resolved
				  at or after the court of appeals:
46. 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:
Title:
Number:
Title:
Number:
Title:
Number:
Title:
Number:
Title:
Number:
Note: If there are more applications, attach additional
					 sheets with the required information.
47. 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):
Title:
Jane Doe vs. ABC
							 Co
Number:
Alameda County No 3
							 76052
Title:
Number:
Title:
Number:
Title:
Number:
Title:
Number:
Title:
Number:
Title:
Number:
Title:
Number:
Title:
Number:
Title:
Number:
Note: If there are more civil actions, attach additional
					 sheets with the required information.
48. 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:
49. The number of employees covered by the
				  Section 3201.5 or
				  3201.7 provision who participated
				  in vocational rehabilitation:
50.
				  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:
51. For an employer, or group of employers,
				  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.
52. 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-1 (012004)
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).
Note: Authority cited: Sections
						133 and
						5307.3, Labor
						Code. Reference: Sections
						3201.5,
						3201.7 and
						3201.9, Labor
						Code.