Exposure Reporting Form

COVID-19 Positive Test Report

Please complete one report for each positive COVID-19 test on form below. If you’d prefer to download the form and submit via email or fax, click here.

This report does not generate a claim or qualify as a reported claim. To submit a claim, please go to www.acmclaims.com or call (866)671-5042.

Per California Labor Code Section 3212.88 – 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.

Positive COVID-19 test results on July 6, 2020 through September 17,2020 must be reported to your claims administrator by October 30, 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).

FAILURE TO REPORT COULD RESULT IN CIVIL FINES UP TO $10,000.

Policy Information

Insured’s name

Policy number

Number of employees

Primary contact

Contact phone

Contact email address

COVID-19 test result information

Date tested for COVID-19

Date of positive COVID-19 test results

Date employer was notified of positive COVID-19 test results

Date employee last worked before positive COVID-19 test results

Specific address/addresses of the employee’s place of employment during the 14-day period preceding the date of the positive test

The highest number of employee’s who reported to work at the employee’s specific place of employment in the 45-day period preceding the last day worked at each specific place of employment

Are there any other positive tests at the location(s)?
YesNo

Is your employee claiming COVID-19 exposure as work related?
YesNo

Has a worker’s compensation claim been filed for your employee?
YesNo

If yes, was a DWC-1 Claim Form provided to the employee?
YesNo