Workers' Compensation


As a Cal Poly Pomona employee, student assistant, or volunteer, if you sustain an injury or illness that you feel was caused by your work, there are 3-steps in reporting your injury or illness and obtaining medical evaluation and treatment:

  1. Notification:  Inform your supervisor immediately if you sustain a work-related injury or illness.

  2. Medical Treatment:  For non-emergency medical evaluation and treatment, your supervisor will provide you with a Authorization form (signed by your supervisor) and refer you for medical treatment at the University's designated industrial medical clinic for evaluation and treatment.

    If you have a current Personal Physician Pre-Designation Form on file with Cal Poly Pomona's Workers' Compensation (must be on file prior to the injury/illness and include the current personal physician's agreement to treat for work-related injuries/illnesses), you may go to your personal physician for evaluation of your work-related injury or illness.  Please contact the Workers' Compensation Coordinator at (909) 869-3725 to verify a current pre-designation is on file.

  3. Reporting Forms:  Work with your manager to complete the Manager's Report of Injury/Illness Form.  Also, you will be provided the Workers' Compensation Claim Form (DWC1).  Please complete and return this form as it initiates the claim process and protects your rights.

Submit forms via our Secure Workers’ Compensation Submission Form (an OnBase/PolyDoc form), sealed inter-office mail (marked as Confidential), or in person within 24 hours of the supervisor’s knowledge. Do not email or fax any documents that contain Social Security numbers or any other personally identifiable information. 

Once your claim form and your manager's reporting forms have been received by the Workers' Compensation Coordinator, a claim will be submitted by us to the university’s workers’ compensation claims administrator, Sedgwick Claims Management Services (CMS).  In addition to receiving a call from us, an account representative of Sedgwick CMS will contact you and ask questions about your injury/illness.

If a work-related injury or illness requires more than first aid treatment, your manager or supervisor should provide you with a Workers' Compensation Claim Form.  Complete and sign the employee portion of this form.

Please contact the Workers' Compensation Coordinator for assistance or if you have any questions about work-related injuries or illnesses.

Telephone:  (909) 869-3725