Reporting Period:On or After 9/17/2020

If you have an employee that has tested positive for COVID-19 on or after September 17, 2020, you are required to promptly notify us with the information required in this form. You are required to report this information to us within three business days of knowledge of the employee's status. You must complete this form whether or not the illness is work-related and whether or not your employee has filed a claim. If your employee contends that the illness is work-related, you must report the claim in addition to completing this form.

If you have more than one employee who has tested positive for COVID-19, you must complete a separate form for each employee. For each employee you report, please keep internal records identifying the employee by name for future reference.

Zenith policy number unable to be found or policy number is for a non-California state. Please confirm the policy number and try again.

Did the employee have a PCR/Viral Test?     Yes   No   I Don't Know

Please provide the information below for each specific place of employment where the employee worked (meaning the actual address of the building, store, facility or agricultural field where the employee performed work at employer's direction) in the 14-day period prior to the testing date. This may be a different location than the business address requested above.

Has the employee filed a Workers' Compensation claim or alleged the illness is work-related?   Yes  No

I hereby certify that I am an authorized representative of the insured named above and the information provided in this form is accurate and complete to the best of my knowledge.