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JOTUSVDUJPOT <br />FNQMPZFF“T!DMBJN!GPS!XPSLFST“!DPNQFOTBUJPO!CFOFGJUT <br />Asofanary1,1990,Californiaemployersarereiredylawtofrnisaclaimformtoaninredworerwitinone <br />woringdayofnowledgeofawor-relatedinryorillnessotertanFirstAid.Wileitismandatoryforteemployer <br />to frnis te claim form to te employee,ju!jt!opu!nboebupsz!gps!uif!fnqmpzff!up!dpnqmfuf!ju/ <br />Teemployersoldcompletesections9-1,witteeceptionofsection13wicreads,"Dateemployer <br />receiedclaimform".Tisistoecompleted bgufs teclaimantascompletedisorerportionofteclaim <br />form and retrned it to yo, at wic time section 13 sold e jnnfejbufmz filled ot or date stamped. <br />PenaltiescaneinoedifemployersfailtoproideaninredemployeeanEMPLOYEESCLAIMFOR <br />COMPESATIOBEEFITSformorifemployersfailtoreportteclaimtoteworerscompensation <br />insrance carrier. <br />EP!OPU!EFMBZ!SFQPSUJOH!B!DMBJN!UP!UIF!IBSUGPSE; <br />WeterornotteemployeecompletesteEMPLOYEESCLAIMFORWORERSCOMPESATIO <br />BEEFITS,pleasecontactTeartfords MpttDpoofdu)2.911.438.4747*toreporteeryoccpationalinryor <br />illness wic reslts in lost time eyond te date of te incident or reires medical treatment eyond First Aid. <br />Gpsn!XD!66!11!22!E Printed in .S.A. <br /> <br />