<p> HOME DEPARTMENT SENDER’S NAME SENDER’S TITLE</p><p>Highlighted areas need to be modified by sender</p><p>MONTH DD, YYYY</p><p>EMPLOYEE NAME EMPLOYEE ADDRESS 1 EMPLOYEE ADDRESS 2</p><p>Re: Workers’ Compensation Injury</p><p>Dear EMPLOYEE NAME,</p><p>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:</p><p>Attn: Workers’ Compensation Risk Management Department Career and Protective Services 3434 South Grand Avenue, CAL 120 Los Angeles, CA 90089-2814</p><p>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. </p><p>Please be advised that your workers’ compensation claim may be delayed if your claim form is not received in a timely manner. </p><p>For questions pertaining to your claim, please call the Workers’ Compensation Department at (213) 740- 6205. </p><p>Best Regards,</p><p>SENDER’S NAME SENDER’S TITLE</p><p>Cc: Workers’ Compensation Department</p><p>University of Southern California • DEPARTMENT ADDRESS• DEPARTMENT TELEPHONE • CONTACT EMAIL</p>