Form DWC-857 "Annual Report of Adjusting Locations" - California

What Is Form DWC-857?

This is a legal form that was released by the California Department of Industrial Relations - Division of Workers' Compensation - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on September 1, 2019;
  • The latest edition provided by the California Department of Industrial Relations - Division of Workers' Compensation;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form DWC-857 by clicking the link below or browse more documents and templates provided by the California Department of Industrial Relations - Division of Workers' Compensation.

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Download Form DWC-857 "Annual Report of Adjusting Locations" - California

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2020 ANNUAL REPORT OF ADJUSTING LOCATIONS
To:
State of California, Department of Industrial Relations
Division of Workers' Compensation, Audit Unit ~ Attn: ARI Desk
160 Promenade Circle, Suite 340
Sacramento, CA 95834-2962
Self-Administered Insurance Company or Group
COMPANY NAME
Third-Party Administrator
COMPANY FEIN
Self-Administered Self-Insured Employer (private or public)
STREET ADDRESS
Self-Administered Joint Powers Authority
CITY/STATE/ZIP
Combination of any of the following, but only if administered under the same
local management. (Check two or more):
MAILING ADDRESS
Self-Administered Insurance Company or Group
CITY/STATE/ZIP
Self-Administered Self-Insured Employer
CONTACT NAME
Third-Party Administrator
TELEPHONE
FACSIMILE
E-MAIL
COMPLAINT CONTACT NAME
COMPLAINT CONTACT MAILING ADDRESS
COMPLAINT E-MAIL ADDRESS
COMPLAINT TELEPHONE
COMPLAINT FACSIMILE NUMBER
Submitted by:
Title:
Date:
Note: Insurer Groups (more than one underwriting company at the same location), third-party administrators, and combinations of the two must complete
Part 2.
A claims administrator, whose obligation to submit an Annual Report of Inventory has been waived in accordance with the California Code of
Regulationstitle 8, section 9701(i), must file an Annual Report of Adjusting locations by April 1 of each calendar year for the previous calendar year.
Failure to timely submit an Annual Report of Adjusting Locations under California Code of Regulations, title 8, section 10104,(d) may be subject to
penalty assessment of up to $500 per location.
Form DWC-857 Rev. 9/2019
2020 ANNUAL REPORT OF ADJUSTING LOCATIONS
To:
State of California, Department of Industrial Relations
Division of Workers' Compensation, Audit Unit ~ Attn: ARI Desk
160 Promenade Circle, Suite 340
Sacramento, CA 95834-2962
Self-Administered Insurance Company or Group
COMPANY NAME
Third-Party Administrator
COMPANY FEIN
Self-Administered Self-Insured Employer (private or public)
STREET ADDRESS
Self-Administered Joint Powers Authority
CITY/STATE/ZIP
Combination of any of the following, but only if administered under the same
local management. (Check two or more):
MAILING ADDRESS
Self-Administered Insurance Company or Group
CITY/STATE/ZIP
Self-Administered Self-Insured Employer
CONTACT NAME
Third-Party Administrator
TELEPHONE
FACSIMILE
E-MAIL
COMPLAINT CONTACT NAME
COMPLAINT CONTACT MAILING ADDRESS
COMPLAINT E-MAIL ADDRESS
COMPLAINT TELEPHONE
COMPLAINT FACSIMILE NUMBER
Submitted by:
Title:
Date:
Note: Insurer Groups (more than one underwriting company at the same location), third-party administrators, and combinations of the two must complete
Part 2.
A claims administrator, whose obligation to submit an Annual Report of Inventory has been waived in accordance with the California Code of
Regulationstitle 8, section 9701(i), must file an Annual Report of Adjusting locations by April 1 of each calendar year for the previous calendar year.
Failure to timely submit an Annual Report of Adjusting Locations under California Code of Regulations, title 8, section 10104,(d) may be subject to
penalty assessment of up to $500 per location.
Form DWC-857 Rev. 9/2019
2020 ANNUAL REPORT OF ADJUSTING LOCATIONS
PART 2
For each individual underwriting company in an insurance group or client of a third-party administrator (whether a self-insured employer or an insurer), whose
claims are administered at the adjusting location, complete the following:
COMPANY NAME
CONTACT NAME
COMPANY FEIN
TELEPHONE
FACSIMILE
MAILING ADDRESS
CITY/STATE/ZIP
E-MAIL
CHECK ONE:
Insurance Company
Self-insured employer (private or public including joint powers authority)
COMPANY NAME
CONTACT NAME
COMPANY FEIN
TELEPHONE
FACSIMILE
MAILING ADDRESS
CITY/STATE/ZIP
E-MAIL
CHECK ONE:
Insurance Company
Self-Insured Employer (private or public including joint powers authority)
COMPANY NAME
CONTACT NAME
COMPANY FEIN
TELEPHONE
FACSIMILE
MAILING ADDRESS
CITY/STATE/ZIP
E-MAIL
CHECK ONE:
Insurance Company
Self-insured employer (private or public including joint powers authority)
2020 ANNUAL REPORT OF ADJUSTING LOCATIONS
Complete and attach additional sheets if necessary.
Form DWC-857 Rev. 9/2019
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