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 10203.2 - Individual Employer Annual Report (DWC Form GV-2)

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
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
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.
				  Name of union 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:
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. 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. 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.
				  Number of claims that were medical only:
9. Total amount of paid costs for medical
				  only claims:
10. Total amount of
				  incurred costs for medical only claims:
11. Number of claims that included a claim
				  for indemnity:
12. Total amount of
				  paid temporary disability for indemnity claims:
13. Total amount of incurred temporary
				  disability for indemnity claims:
14. Total amount of paid permanent disability
				  for indemnity claims:
15. Total
				  amount of incurred permanent disability for indemnity claims:
16. Total amount of paid life pensions for
				  indemnity claims:
17. Total amount
				  of incurred life pensions for indemnity claims:
18. Total amount of paid death benefits for
				  indemnity claims:
19. Total amount
				  of incurred death benefits for indemnity claims:
20. Total amount of paid vocational
				  rehabilitation for indemnity claims:
21. Total amount of incurred vocational
				  rehabilitation for indemnity claims:
22. Total amount of paid medical services for
				  indemnity claims:
23. Total amount
				  of incurred medical services for indemnity claims:
24. Total amount of paid medical legal
				  expenses for indemnity claims:
25.
				  Total amount of incurred medical legal expenses for indemnity claims:
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. 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. The number of claims that were resolved
				  with a denial of compensability:
29. The number of claims that were resolved
				  before mediation:
30. The number of
				  claims that were resolved at or after mediation:
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. The
				  number of claims that were resolved at or after the Workers' Compensation
				  Appeals Board (WCAB):
33. The
				  number of claims that were resolved at or after the court of appeals:
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. 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. 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. The number of employees covered by the
				  Section 3201.5 or
				  3201.7 provision who participated
				  in vocational rehabilitation:
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. 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.
				  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)
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.