SLIDE 63 Filing a Claim: Instructions for Volunteers
- Step 1: The injured DSW volunteer (or a relative or legal representative if the DSW volunteer is incapacitated)
must complete the top section of the SCIF Form 3301 (lines 1 through 8), in its entirety. Select line Instructions:
- 4: Date and time of injury: For a specific injury, give the date the accident occurred. If the DSW is
alleging a cumulative trauma over a period of time, list the date of the most recent exposure. For example, if a DSW volunteer contracted pneumonia as a result of prolonged exposure working outside in bad weather, list the first date of the alleged exposure through the date symptoms were apparent.
- 5: Address and description of where injury happened: Give as much detail as possible to describe the
location of the accident. This information is helpful in determining if the incident occurred as alleged and if it occurred in the course of disaster service work, resulting in a covered injury.
- 6: Describe injury and part of body affected: It is important to describe all parts of the body believed
to be injured. The supervising agency reserves the right to have an appropriate medical specialist address the probability of any injury resulting from an accident or activity, as alleged.
- 8: Signature: It is important that the DSW volunteer (or their representative) sign the claim form. In
doing so, the DSW volunteer: takes responsibility that the information provided is correct; and, acknowledges they have read and understand the fraud disclaimer printed at the top of the form.
- Step 2: The injured DSW volunteer retains the copy marked Employee's Temporary Receipt. This is the DSW
volunteer's receipt of record that the claim was filed with the supervising agency.
- Step 3: Submit the signed form and the remaining copies to the team leader or supervisor within 3 days (or 72
hours) of receiving the form. This document is part of the claim package that will be sent to SCIF to initiate the claim process.
http://content.statefundca.com//p df/e3301.pdf