COVID-19 Positive Test Report
Please complete one report for each positive COVID-19 test. Submit by email to
COVIDREPORTING@Aims4Claims.com, with cc: to jbwcp@jud.ca.gov or by fax to (916) 563-1919.
Note: This report does not generate a claim, nor does a claim qualify as a report. To submit a claim, please follow your internal reporting procedures
.
Overview
If you are aware of an employee testing positive for COVID-19 on or after July 6, 2020, you must report it to your
claims administrator (California Labor Code Section 3212.88).
•
Positive COVID-19 test results on or from July
6,
2020 through September
17,
2020 must be reported to your
claims administrator by October 29, 2020.
•
Positive COVID-19 test results after September 17, 2020 require reporting within 3 business days of
knowledge (or when it should reasonably have been known).
Employer information
Employer Name:
__________________________________________________________________________________________
Number of employees: Primary contact:
______________________________________
Contact phone: Contact Email:
________________________________________
Fax: Today’s date:
____________________________________
COVID-19 test result information
Tracking Number:
________________________
This is an internal number you assign to track what has been reported. Do not include any Personal Identifiable
Information (such as SSN, DOB, etc.) in this report.
Reported as Industrial: ____Yes ______No
Date of positive COVID-19 test:
_____________________
This is the sample collection date. Test must be a Polymerase Chain Reaction (PCR) or other viral testing approved
by the FDA. Serologic (antibody) testing is not a viable test.
Date employer notified of positive COVID-19 test result:
____________________________
Date employee last worked before positive COVID-19 test result:
__________________________
