Understanding Labor Code § 4906 — What It Requires and Why It Matters

California’s workers’ compensation system has many rules designed to keep the process transparent and fair. Among them, Labor Code § 4906(h) is one of the most important for employers, insurers, and claims examiners to understand and implement consistently.

This section requires all parties to confirm, under penalty of perjury, that no improper inducements or referral arrangements influenced the handling of a claim.

By embedding § 4906(h) compliance into your claims workflow, you can avoid delays, reduce risk, and ensure every case is properly filed from day one.

Key Provisions of Labor Code § 4906 (h)

Under Labor Code § 4906(h):

• Who must sign?
  Every party involved — the injured worker, the employer, the insurer and their claims administrator (in some cases this means two declarations are necessary – more about this below), and attorneys for both sides — must sign a declaration.
• What does the declaration say?
  That the signer:
  • Has not violated Labor Code § 139.3 (the anti-kickback provision).
  • Has not offered, delivered, accepted, or received any money, rebate, discount, or other benefit in exchange for a referral for an examination or evaluation.
  • The following disclosure must be included: “Any person who makes or causes to be made any knowingly false or fraudulent material statement or representation for the purpose of obtaining or denying workers’ compensation benefits or payments is guilty of a felony.”
• When is it required?
  The signed § 4906(h) declaration must accompany pleadings such as an Application for Adjudication of Claim or an Answer. If missing, the WCAB may refuse to file the pleading or impose sanctions for non-compliance.

• Why is this important?
  Failure to comply with this Labor Code could result in the WCAB refusing to accept filings or issuing sanctions against a party. Compliance is not optional — it’s critical, and these declarations must be filed either with an Application or Answer, or a Stipulation with Request for Award or Compromise & Release filed as the case opening documents.

Practice & Procedure – Compliance Made Simple

Making § 4906(h) part of your standard claims process doesn’t have to be complicated. By incorporating the declaration into routine intake and referral steps, employers and insurers can ensure compliance, avoid delays, and keep claims moving smoothly through the system

For Employers

• Complete and sign a § 4906(h) declaration for when you submit a Form 5020 (Employer’s First Report of Injury/Illness).
• Send the signed form to your insurer or claims administrator with new claims.
• If the employer is out of business or there is no employer to sign the form you will need to work with your defense attorney to formulate an affidavit related to why the employer is unable to complete the § 4906(h) declaration. 

For Insurers / Claims Administrators

• Include a blank § 4906(h) declaration with the claim acknowledgement package sent to the employer.
• Request the signed form back as part of your initial claim intake checklist and continue to follow up with the employer until you received the signed form back.
• The claims examiner should provide a fully executed § 4906(h) declaration for both the administrator and the carrier.  If the carrier administers its own claims, they will only need one § 4906(h) declaration.
• If you are a Third Party Claims Administrator (or a Claims Administrator wholly owned by a carrier but not using the same name/dba as the carrier) then two separate § 4906(h) declarations may be required – one for the carrier (obligated to pay the claim) and one for the TPA or the claims administrator (named as the administrator in EAMS) who is administering benefits.

For Litigation Referrals

• Include the executed § 4906(h) declarations from all three entities the employer, the claims administrator and insurer to defense counsel along with the initial claim documents.
• Counsel will ensure all required party and attorney declarations are filed with the WCAB.

Quick Checklist ✅

• Employer executes § 4906(h) with Form 5020
• Insurer circulates blank § 4906(h) with claim acknowledgement packet to employers
• Claims examiner confirms signed declarations are in the claim file from both the Insurance Carrier and the Claims Administrator
• Litigation referral package includes executed § 4906(h) forms
• Counsel files all required declarations with the WCAB

📄 Download the form here: DECLARATION PURSUANT TO LABOR CODE SECTION 4906(h)