Employee Name

HOME DEPARTMENT SENDER’S NAME SENDER’S TITLE

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MONTH DD, YYYY

EMPLOYEE NAME EMPLOYEE ADDRESS 1 EMPLOYEE ADDRESS 2

Re: Workers’ Compensation Injury

Dear EMPLOYEE NAME,

We have been notified that you sustained an injury that may be work-related. California State law requires that we provide you with a Workers’ Compensation Claim Form (DWC-1) within 24 hours of notice of your injury. If you want to file a claim for workers’ compensation benefits, please complete the enclosed claim form and keep a copy for your records. Please send the completed claim form back to:

Attn: Workers’ Compensation Risk Management Department Career and Protective Services 3434 South Grand Avenue, CAL 120 Los Angeles, CA 90089-2814

If you have not already completed a Supervisor’s Report of Injury with your Supervisor or Home Department Coordinator, please call ###-###-#### so that a file can be established for your claim.

Please be advised that your workers’ compensation claim may be delayed if your claim form is not received in a timely manner.

For questions pertaining to your claim, please call the Workers’ Compensation Department at (213) 740- 6205.

Best Regards,

SENDER’S NAME SENDER’S TITLE

Cc: Workers’ Compensation Department

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