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Complete this form to the best of your ability and return in the enclosed envelope. If you have any questions, please do not hesitate to contact us. I. Employment History Beginning with your job on your last day worked please describe each job you worked at during the past 15 years. Please include a resume, if available. If you held more than one job with the same employer, please list each job separately. 1. Name of Employer: Job Title: Start Date: End Date: Annual Salary: Reason for Leavin.

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The Division of Workers' Compensation (DWC) monitors the administration of workers' compensation claims, and provides administrative and judicial services to assist in resolving disputes that arise in connection with claims for workers' compensation benefits.

The employer shall: Assure that first aid is administered for minor injuries or arrange medical treatment by an employer selected physician or the employee's pre-designated physician when necessary. For extreme emergency get the injured to any available doctor, hospital, or public medical service.

The state of California requires almost all employers to be legally liable for injuries to employees that occur on the job, regardless of where those injuries took place. California law has always been on the side of employees who are injured while working off-site. Remote employees are no different.

If it's an emergency, call 911 or go to an emergency room right away. Tell the medical staff that your injury or illness is job-related. If you can safely do so, contact your employer for further instructions. If you don't need emergency treatment, make sure you get first aid and see a doctor if necessary.

If you were injured after Apr. 19, 2004, your TD payments won't last more than 104 weeks within a period of 2 years from the first payment for most injuries. If you were injured after Jan. 1, 2008, your TD payments won't last more than 104 weeks within a period of 5 years from the date of your injury.

Employers must report to OSHA work-related fatalities within 8 hours of finding out about it. For any in-patient hospitalization, amputation, or eye loss employers must report the incident to OSHA within 24 hours of learning about it.

In cases where a worker's own behavior resulted in an accident, employers are still responsible for ensuring the workers' safety if the accident occurred on company property or on company time. They are also responsible for making sure that the employee receives medical treatment.

To make up for missed wages, an employee with a work-related injury or illness is eligible to receive up to two-thirds of their pre-injury average weekly earnings. Temporary total disability benefits begin after they can't work for more than three consecutive calendar days.

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© Copyright 1997-2025
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Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232