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State of California Esmdo de Cd9romita Department of Industrial Relations Lepanaznerto de Pelaciaws lydeianales DIVLSIONOFWORKERS'COMPENSATION - DImomDECOMPEzirswz mAL7RABAJADOR W� WORKERS'COMPENSATION CLAIM FORM(DWC 1) - " PETITION DEL EMPLEADO PARR DE COMPENSAC16N DEL IRA BAJADOR(DWC I) Employee Complete the"Erpioyee"section and give the form to your " Empleado: Complete la secci in `Empeeado"y errregue la forma a su employer.Keep a copy and mark it"Employee's Temporary Receipt"until emp'eador. Qigdese con la capia rizsigrnda Rwiha Tempvroi dd you receive the signed and dated copy from your employer. You may call the Empleado"pasta que Ud rwrba la copra firmada y fechada de su empleador. Ud puseale Qamar a la Division de Canpowoci6n al T rabajador al(Stet)736. Division of Wakes'Compensation and hear recorded information at(80d) 7401 pain air mformacOn gravada. Una exp'kacOn de las beneficias de 7367401.An acplanation of workers'compensation benefits is included in canpmsacidn de rmbajalores esid md'uido en 14 Notifract6n ik Posible the Notice of Potential Eligibility,which is the cover sheet of this form Elegibilida4 que es la hoja de portada de esta forma Separe y guarie ester Detach and save this notice for future reference. ndificaci6n cono reorexia para el fid:vo. You mould also have received a pamphlet from your employer describing Ut mmbign deberla haler reabido de su empleador zm fes'leto descnbierdo waters'ompesatim benefits and the procedures to obtain than You may los benjlcios de ca ipemacOn at trabajador lesimzdo y los procednniauos receive written notices from your employer or its claims administrator about pars obtezertar. Fs posWe quo waba notEftmioms escrta de su your claim If your claims administrator offers to send you notices eVkador o de su admmis7ador aie redanos sabre su reclamo. St su electronically,and you agree to receive these notices only by email;please admoustrador de reclamos ofrece euviade nrtifrcaciazes eleetrdnicanente,y toted acepta recibir eras notifrcaciaws solo par correo ekdr6nko,par provide your email address below and ehedc the appropriate box If you late favor prcporctom su direccidn de correo ekar6nico abajo y marque la caja decide you want to receive the notices by nail, you must inform your apropiada.Si usted decide daputt que qukre recibir has ndificaiaws por employer in writing correo,usted debe de Pnrormar a su empleador por escrto. Any person vilo o makes or caus es to be made any knowinpj.y false or TDda aquelle,pe rsona clue a prop asito haga o cause que se produzca i fraudulent material statement or material representation for the cua Iquier dec la rac ion a representacidn materia I fadsa a frauduienta con payments is guilty of a felony. trabajadmes lesionadoe,es culpable de un crimen mayor"felonial. Employee—complete this section and we note above Empkado complete estaseceidn y note la notaci6n arnba. 1.Name Nonbre. Today's Date.Fecha de Hoy. 2 Home Address.Dinem6n PesiderriaL 3.City.Cdtdad State.Esiado. Zip.C6d(go Postal. 4.Date of Injury.Fecha de la lai6n(axidw&). Time of Injury.Hora in que crurrO. a.m. p in 5.Address and description of where injury happened.Direcribndugar diode occurid el acciderte. 6.Describe injury and part of body affected.Describa la lesidn y parte del cuerpo afedada. 7.Social Security Number.Ntimero de Seguro social del Empleado. 8. ❑Check if you agree to receive notices about your claim by email only. ❑Manpw si mted acepm recibir nrtificaciazes sobre su reclamo solo par correo etectr6nko.Employee's e-mail. Correoekdrinkodel empleada You will receive benefit notices by regular mail if you do not choose,or your claims administrator does not offer,an electronic service option. Usted recibird nottficaiazes de benefriosporcormo ordrnanosi ustedno escoge,asuadmmistradorde reclamas no le ofnwce,zma clocibnde servicio ekdrzinico. 9.Signature of erployee.Firma del empleado. Employer--comp fete this section and see note below.Empleador---complete esta seccidn y mole la nolaci6n ab*. 10.Name of employer.Nombre del empleador. San Joaquin County 11.Address.Dire cci6n. 44 N.San Joaquin St.,#330,Stockton,CA 95202 12.Date employer first knew of injury.Fecha en que el empleador supo por prunera vez de la lesi6n o occderte. 13.Date claim form was provided to employee.Fecha m que se leertreg6al empieadolapeticlirz 14.Date employer received claim form Fecha en que el empleado devolvi6la petki6n al empkador. 15.Name and address of insurance carrier or adjusting agency.Nombre ydirecci6n dela compoNadeseguros oWwia a inustradora de seguros. TR[STAR Risk Management,P.O.Box 2805,Clinton,IA 52733-2805 16.Insurance Policy Number.El raunero de la p6l as de Seguro.Self-inSllred 17.Signature of employer representative.PYrma del represe vizitede.'empleador. 18.Title.Tlado. 19. Telephone.Telefono. Employer.You are required to date this form and provide copies to your insurer Empleador.•Se requiere que Ud feche esm forma y que prou4a copiers a su or claims administrator and to the employee,dependent or representative who covzpaYiade segunx,admmititrador de redanas,o dependiertdrepresertaae de filed the claim within one working day ofreoeiptofthe form from the employee redanosyalempleadoquehayanpmsertadoestap3kibnd rrodelpkzode SIGNING THIS FORM IS NOT AN ADMISSION OF LdABILIT'Y nn dia h6MJ.desde el ma wnro de habersido recibida la forma del empleado. EL FIRMARESTA FOP VANOS7GWFICAADMISIONDEREYPONSABILILAD ❑Employercopy/Ccpiadel Emple�or❑Employee mpylCopw del Empleado ❑Clams Adm,trator/Adk=l,vd..-rb Ead—m ❑Temporary Rempt/Rarihu dot Emplaa$ Rev.1/1/2016 San Joaquin County Department of Public Works County of San Joaquin Dept of Public Works IIPP Rev 2020-01-31.docx P a g e 27