10

NOTICE TO EMPLOYEELabor Code section 2810.5

EMPLOYEE

Employee Name:

Start Date:

EMPLOYER

Legal Name of Hiring Employer:

Is hiring employer a staffing agency/business (e.g., Temporary Services Agency; Employee Leasing

Other Names Hiring Employer is "doing business as" (if applicable):

Physical Address of Hiring Employer’s Main Office:

Hiring Employer’s Mailing Address (if different than above):

Hiring Employer’s Telephone Number:

If the hiring employer is a staffing agency/business (above box checked "Yes"), the following is the other entity

for whom this employee will perform work:

Name:

Physical Address of Main Office:

Mailing Address:

Telephone Number:

WAGE INFORMATION

Rate(s) of Pay: Overtime Rate(s) of Pay:

Does a written agreement exist providing the rate(s) of pay

If yes, are all rate(s) of pay and bases thereof

Allowances, if any, claimed as part of minimum wage (including meal or lodging allowances):

(If the employee has signed the acknowledgment of receipt below, it does not constitute a “voluntary written agreement” as required under the law between the employer and employee in order to credit any meals or lodging against the minimum wage. Any such voluntary written agreement must be evidenced by a separate document.)

Regular Payday:

Route 66 HR Outsourcing

�

Strategic Outsourcing

3023 HSBC Way, Suite 200, Fort Mill, SC 29707

1-800-572-2412

11

a. May accrue paid sick leave and may request and use up to 3 days or 24 hours of accrued paid sick leave per year;

b. May not be terminated or retaliated against for using or requesting the use of accrued paid sick leave; and c. Has the right to file a complaint against an employer who retaliates or discriminates against an employee for 1. requesting or using accrued sick days; 2. attempting to exercise the right to use accrued paid sick days;

3. filing a complaint or alleging a violation of Article 1.5 section 245 et seq. of the California Labor Code; 4. cooperating in an investigation or prosecution of an alleged violation of this Article or opposing any policy

or practice or act that is prohibited by Article 1.5 section 245 et seq. of the California Labor Code. The following applies to the employee identified on this notice: (Check one box)

1. Accrues paid sick leave only pursuant to the minimum requirements stated in Labor Code §245 et seq. with no other employer policy providing additional or different terms for accrual and use of paid sick leave.

2. Accrues paid sick leave pursuant to the employer’s policy which satisfies or exceeds the accrual, carryover, and use requirements of Labor Code §246.

3. Employer provides no less than 24 hours (or 3 days) of paid sick leave at the beginning of each 12-month period. 4. The employee is exempt from paid sick leave protection by Labor Code §245.5. (State exemption and specific

subsection for exemption):________________________________________________________________________

(Optional) _______________________________________ ______________________________________ (PRINT NAME of Employer representative) (PRINT NAME of Employee) _______________________________________ ______________________________________ (SIGNATURE of Employer Representative) (SIGNATURE of Employee) _______________________________________ ______________________________________ (Date) (Date)

The employee’s signature on this notice merely constitutes acknowledgement of receipt.

ACE AMERICAN INSURANCE COMPANY

436 Walnut Street, P.O. Box 1000, Philadelphia, PA 19106-3703

415-547-4450

12

DE 35 Rev. 14 (5-13) (INTERNET) Page 1 of 2 CU

NOTICE TO EMPLOYEES Your employer must send a copy of your Employee’s Withholding Allowance Certificate (Form W-4 [federal] or DE 4 [state]) to the Franchise Tax Board (FTB) if the form meets either of the following two conditions: You claim more than 10 withholding allowances.

You claim to be exempt from state or federal income tax withholding and your employer

expects your usual weekly wages to exceed $200. Your employer will continue to treat the Form W-4 and/or DE 4 as valid until notified, in writing, by the FTB of the proper marital status and number of allowances to use for California Personal Income Tax (PIT) withholding purposes. If you disagree with the FTB determination, you may request a review of the determination by writing to: W-4 Unit Franchise Tax Board MS F180 P.O. Box 2952 Sacramento, CA 95812-2952 Fax: 916-843-1094 You, as the employee, will have to provide proof that the FTB determination is incorrect for California PIT withholding purposes. Your employer must continue to withhold as instructed in the original determination until notified by the FTB, in writing, of any changes. If the FTB finds that the number of withholding allowances you claimed is unreasonable, you may be subject to a $500 penalty as provided by Section 13101 of the California Unemployment Insurance Code.

- Versión en español en la página 2 -

13

H

ow t

o C

laim

Sta

te P

lan

Ben

efits

1. U

se S

DI

Onl

ine

to s

ecur

ely

file

for

bene

fits

or

requ

est a

pap

er c

laim

form

.B

y In

tern

et: w

ww

.edd

.ca.

gov/

disa

bilit

y.B

y ph

one:

1-8

00-4

80-3

287.

By

mai

l: ED

D, D

isab

ility

Insu

ranc

e,

PO B

ox 9

8977

7, W

est S

acra

men

to, C

A

9579

8-97

77.

In p

erso

n by

vis

iting

any

of t

he D

I offi

ces

liste

d un

der “

DI O

ffice

Loc

atio

ns.”

Cal

iforn

ia s

tate

gov

ernm

ent e

mpl

oyee

s co

vere

d by

SD

I sho

uld

call

1-86

6-35

2-76

75.

2. W

hen

filin

g SD

I Onl

ine,

com

plet

e al

l re

quir

ed fi

elds

. A r

ecei

pt n

umbe

r w

ill b

e ge

nera

ted

whe

n yo

ur c

laim

is s

ubm

itted

.

If us

ing

a pa

per

clai

m fo

rm, c

ompl

ete

and

sign

the

“Cla

im S

tate

men

t of E

mpl

oyee

.” P

rint

cl

earl

y, a

nd v

erify

you

r an

swer

s ar

e co

mpl

ete

and

corr

ect a

s er

rors

del

ay p

aym

ents

.3.

Hav

e yo

ur p

hysi

cian

/pra

ctiti

oner

com

plet

e th

e “P

hysi

cian

/Pra

ctiti

oner

Cer

tifica

tion”

on

line

or u

se th

e pa

per

clai

m fo

rm. I

f filin

g on

line,

you

r ph

ysic

ian/

prac

titio

ner

will

ne

ed y

our

rece

ipt n

umbe

r to

com

plet

e th

e “P

hysi

cian

/Pra

ctiti

oner

Cer

tifica

tion.

”

Usu

ally

a c

laim

can

not b

egin

mor

e th

an

seve

n da

ys b

efor

e yo

u w

ere

exam

ined

by

or

unde

r th

e ca

re o

f a p

hysi

cian

/pra

ctiti

oner

. C

ertifi

catio

n m

ay b

e m

ade

by a

lice

nsed

m

edic

al o

r os

teop

athi

c ph

ysic

ian

and

surg

eon,

nur

se p

ract

ition

er, c

hiro

prac

tor,

dent

ist,

podi

atri

st, o

ptom

etri

st, d

esig

nate

d ps

ycho

logi

st, o

r an

aut

hori

zed

med

ical

of

ficer

of a

Uni

ted

Stat

es g

over

nmen

t fac

ility

. C

ertifi

catio

n m

ay a

lso

be m

ade

by a

lice

nsed

nu

rse-

mid

wife

or

licen

sed

mid

wife

for

disa

bilit

ies

rela

ted

to n

orm

al p

regn

ancy

or

child

birt

h.4.

File

onl

ine

or s

ubm

it yo

ur p

aper

cla

im fo

rm

with

in 4

9 da

ys fr

om th

e fir

st d

ay y

ou w

ere

disa

bled

. If y

our

clai

m is

late

, you

may

lose

be

nefit

s un

less

you

r ex

plan

atio

n of

the

dela

y is

acc

epte

d as

rea

sona

ble.

The

EDD

is

an e

qual

opp

ortu

nity

em

ploy

er/p

rogr

am.

Aux

iliar

y ai

ds a

nd s

ervi

ces

are

avai

labl

e up

on re

ques

t to

indi

vidu

als

with

dis

abili

ties.

Req

uest

s fo

r se

rvic

es, a

ids,

an

d/or

alte

rnat

e fo

rmat

s ne

ed to

be

mad

e by

cal

ling

DI a

t 1-

866-

490-

8879

(voi

ce),

or th

roug

h th

e C

alifo

rnia

Rel

ay

Serv

ices

at 7

11.

This

pam

phl

et is

for

gene

ral i

nfo

rmat

ion

onl

y,

and

do

es n

ot

have

the

forc

e an

d e

ffec

t o

f the

law

, ru

le o

r re

gula

tio

n.

Dis

abili

ty is

an

illne

ss o

r in

jury

, eith

er p

hysi

cal

or m

enta

l, w

hich

pre

vent

s cu

stom

ary

wor

k.

Dis

abili

ty in

clud

es e

lect

ive

surg

ery,

pre

gnan

cy,

child

birt

h, o

r re

late

d m

edic

al c

ondi

tions

.

Dis

abili

ty I

nsur

ance

(D

I) is

a c

ompo

nent

of t

he

Stat

e D

isab

ility

Insu

ranc

e (S

DI)

prog

ram

, des

igne

d to

par

tially

rep

lace

wag

es lo

st d

ue to

a n

on-w

ork-

rela

ted

disa

bilit

y (s

ee “

Oth

er P

rogr

ams,

” fo

r jo

b-re

late

d di

sabi

litie

s).

SDI c

ontr

ibut

ions

are

pai

d by

Cal

iforn

ia w

orke

rs

cove

red

by th

e SD

I pro

gram

. Con

trib

utio

n ra

tes

may

var

y fr

om y

ear

to y

ear.

For

curr

ent r

ates

, vis

it th

e D

I web

site

at w

ww

.edd

.ca.

gov/

disa

bilit

y,

or c

onta

ct th

e Em

ploy

men

t Dev

elop

men

t D

epar

tmen

t (ED

D) D

isab

ility

Insu

ranc

e cu

stom

er

serv

ice

at 1

-800

-480

-328

7 or

ED

D e

mpl

oym

ent

tax

cust

omer

ser

vice

at 1

-888

-745

-388

6.

DI

Plan

s

Stat

e Pl

an. T

he D

I sta

te p

lan

is c

over

ed in

this

br

ochu

re.

Vol

unta

ry P

lan

(VP)

. A p

rivat

e pl

an, a

ppro

ved

by th

e D

irec

tor

of th

e ED

D, w

hich

may

be

subs

titut

ed fo

r th

e St

ate

Plan

. Vol

unta

ry P

lans

m

ay b

e es

tabl

ishe

d if

the

empl

oyer

and

m

ajor

ity o

f em

ploy

ees

agre

e to

do

so. V

P in

form

atio

n an

d fil

ing

a cl

aim

may

be

done

th

roug

h yo

ur e

mpl

oyer

. If y

ou a

re c

over

ed b

y a

VP,

the

prov

isio

ns o

f thi

s br

ochu

re m

ay n

ot

appl

y to

you

. Obt

ain

info

rmat

ion

abou

t you

r co

vera

ge a

nd fi

le a

VP

clai

m th

roug

h yo

ur

empl

oyer

.

Elec

tive

Cov

erag

e (E

C).

Empl

oyer

s an

d se

lf-em

ploy

ed p

erso

ns, i

nclu

ding

gen

eral

par

tner

s,

may

ele

ct c

over

age.

The

met

hod

of c

ompu

ting

bene

fits

for

EC p

artic

ipan

ts is

not

the

sam

e as

for

man

dato

ry r

ate

paye

rs. T

he c

ost o

f pa

rtic

ipat

ing,

whi

ch is

set

ann

ually

, can

be

obta

ined

from

you

r lo

cal E

DD

Em

ploy

men

t Tax

C

usto

mer

Ser

vice

Offi

ce.

EC c

laim

s ar

e fil

ed in

the

sam

e m

anne

r as

St

ate

Plan

cla

ims;

how

ever

, the

re a

re s

ome

diffe

renc

es in

elig

ibili

ty r

equi

rem

ents

from

th

ose

liste

d in

this

pam

phle

t.

cove

rage

, con

tact

ED

D D

I cus

tom

er s

ervi

ce

at 1

-800

-480

-328

7, E

DD

em

ploy

men

t tax

cu

stom

er s

ervi

ce a

t 1-8

88-7

45-3

886,

or

visi

t ou

r w

ebsi

te a

t ww

w.e

dd.c

a.go

v/di

sabi

lity.

DIS

AB

ILIT

YIN

SUR

AN

CE

PRO

VIS

ION

S

DE

2515

Rev

. 63

(11-

15) (

INTE

RN

ET)

Page

1 o

f 2

CU

DI

Offi

ce L

ocat

ions

& M

ailin

g A

ddre

sses

Chi

co ..

......

......

......

......

......

.....

645

Sale

m S

tree

t(P

O B

ox 8

190,

Chi

co, C

A 9

5927

-819

0)

Chi

no H

ills .

..153

15 F

airfi

eld

Ranc

h Ro

ad, S

te. 1

00(P

O B

ox 6

0006

, City

of I

ndus

try,

CA

917

16-0

006)

Fres

no ..

......

...25

50 M

arip

osa

Mal

l, R

m. 1

080A

(PO

Box

32,

Fre

sno,

CA

937

07-0

032)

Long

Bea

ch ..

.430

0 Lo

ng B

each

Blv

d., S

te. 6

00(P

O B

ox 4

69, L

ong

Bea

ch, C

A 9

0801

-046

9)

Los

Ang

eles

.....

.888

S. F

igue

roa

Stre

et, S

te. 2

00(P

O B

ox 5

1309

6, L

os A

ngel

es, C

A 9

0051

-109

6)

Oak

land

.....

......

. 76

77 O

akpo

rt S

tree

t, St

e. 3

25(P

O B

ox 1

857,

Oak

land

, CA

946

06-1

857)

Riv

ersi

de ..

......

1190

Pal

myr

ita A

venu

e, S

te. 1

00(P

O B

ox 5

9903

, Riv

ersi

de, C

A 9

2517

-990

3)

Sacr

amen

to ..

......

......

......

......

....5

009

Bro

adw

ay(P

O B

ox 1

3140

, Sac

ram

ento

, CA

958

13-3

140)

San

Ber

nard

ino

.....

......

......

371

Wes

t 3rd

Str

eet

(PO

Box

781

, San

Ber

nard

ino,

CA

924

02-0

781)

San

Die

go ..

.924

6 Li

ghtw

ave

Aven

ue, B

ldg.

A, S

te. 3

00(P

O B

ox 1

2083

1, S

an D

iego

, CA

921

12-0

831)

San

Fran

cisc

o ...

....7

45 F

rank

lin S

tree

t, R

m. 3

00(P

O B

ox 1

9353

4, S

an F

ranc

isco

, CA

941

19-3

534)

San

Jose

.....

......

......

....

297

Wes

t Hed

ding

Str

eet

(PO

Box

637

, San

Jose

, CA

951

06-0

637)

Sant

a A

na ...

605

Wes

t San

ta A

na B

lvd.

, Bld

g. 2

8, R

m. 7

35(P

O B

ox 1

466,

San

ta A

na, C

A 9

2702

-146

6)

Sant

a B

arba

ra ..

......

......

...12

8 Ea

st O

rteg

a St

reet

(PO

Box

152

9, S

anta

Bar

bara

, CA

931

02-1

529)

Sant

a R

osa

.....

......

......

606

Hea

ldsb

urg

Ave

nue

(PO

Box

700

, San

ta R

osa,

CA

954

02-0

700)

Stoc

kton

.....

......

..31

27 T

rans

wor

ld D

r., S

te. 1

50(P

O B

ox 2

0100

6, S

tock

ton,

CA

952

01-9

006)

Cal

iforn

ia S

tate

Gov

ernm

ent E

mpl

oyee

s(P

O B

ox 2

168,

Sto

ckto

n, C

A 9

5201

-216

8)

Van

Nuy

s ...

......

.154

00 S

herm

an W

ay, R

m. 5

00(P

O B

ox 1

0402

, Van

Nuy

s, C

A 9

1410

-040

2)

14

How

Ben

efits

Are

Pai

d

mai

l. Yo

u do

not

nee

d to

app

ear

in p

erso

n to

ap

ply

or r

ecei

ve b

enefi

ts.

SM.

The

EDD

Deb

it C

ardSM

wor

ks li

ke o

ther

de

bit c

ards

, giv

ing

you

acce

ss to

fund

s 24

ho

urs

a da

y, 7

day

s a

wee

k, a

nd c

an b

e us

ed

ever

ywhe

re V

isa®

deb

it ca

rds

are

acce

pted

. W

hen

your

cla

im is

rec

eive

d, y

ou m

ay b

e co

ntac

ted

thro

ugh

SDI O

nlin

e, b

y ph

one,

or

by

mai

l for

add

ition

al in

form

atio

n. M

ost

prop

erly

com

plet

ed c

laim

s ar

e pr

oces

sed

with

in 1

4 da

ys.

non-

paya

ble

wai

ting

peri

od.

Ben

efits

are

pai

d as

qui

ckly

as

poss

ible

afte

r al

l in

form

atio

n to

det

erm

ine

elig

ibili

ty is

rec

eive

d.

If yo

u m

eet a

ll el

igib

ility

req

uire

men

ts, b

enefi

ts

will

be

auth

oriz

ed. I

f you

are

elig

ible

for

furt

her

bene

fits,

you

will

be

auth

oriz

ed a

dditi

onal

be

nefit

s el

ectr

onic

ally

or

sent

a “

cont

inue

d cl

aim

” ce

rtifi

catio

n fo

rm fo

r yo

u to

com

plet

e fo

r th

e ne

xt b

enefi

t per

iod.

Usu

ally

thes

e be

nefit

pe

riod

s ar

e fo

r tw

o-w

eek

inte

rval

s. H

owev

er, D

I pa

ys b

enefi

ts b

ased

on

daily

elig

ibili

ty w

ithin

a

seve

n-da

y ca

lend

ar w

eek.

Par

tial w

eeks

are

pai

d at

a d

aily

rat

e. T

his

rate

is o

ne-s

even

th o

f you

r w

eekl

y be

nefit

am

ount

. Ple

ase

allo

w 1

0 da

ys

from

the

date

you

mai

l or

elec

tron

ical

ly s

ubm

it a

cert

ifica

tion

for

rece

ipt o

f pay

men

t.H

ow Y

our

Ben

efit

Rat

e is

Det

erm

ined

Ben

efit a

mou

nts

are

base

d on

wag

es p

aid

duri

ng

a sp

ecifi

c 12

-mon

th b

ase

peri

od, d

eter

min

ed

by th

e da

te y

our

clai

m b

egin

s. C

onsi

der

whe

n to

sta

rt y

our

clai

m s

ince

this

may

affe

ct y

our

wee

kly

bene

fit r

ate,

you

r m

axim

um b

enefi

t am

ount

, and

the

peri

od o

f you

r be

nefit

elig

ibili

ty.

Onl

y ba

se p

erio

d w

ages

sub

ject

to th

e SD

I co

ntri

butio

ns c

an b

e us

ed in

com

putin

g yo

ur

bene

fits.

To

qual

ify, y

ou m

ust h

ave

earn

ed a

t le

ast $

300

duri

ng y

our

base

per

iod.

The

mon

th

your

cla

im b

egin

s de

term

ines

whi

ch fo

ur

cons

ecut

ive

quar

ters

are

use

d.If

your

cla

im b

egin

s in

:Ja

nuar

y, F

ebru

ary,

or

Mar

ch, y

our

base

per

iod

is th

e 12

mon

ths

endi

ng la

st S

epte

mbe

r 30

. (E

xam

ple:

A c

laim

beg

inni

ng F

ebru

ary

14, 2

015,

uses

a b

ase

perio

d of

Oct

ober

1, 2

013,

thro

ugh

Sept

embe

r 30,

201

4.)

Apr

il, M

ay, o

r Ju

ne, y

our

base

per

iod

is t

he

12 m

onth

s en

ding

last

Dec

embe

r 31

. (E

xam

ple:

A c

laim

beg

inni

ng Ju

ne 2

0, 2

015,

us

es a

bas

e pe

riod

of J

anua

ry 1

, 201

4, th

roug

h D

ecem

ber

31, 2

014.

)

July

, Aug

ust,

or

Sept

embe

r, yo

ur b

ase

peri

od is

th

e 12

mon

ths

endi

ng la

st M

arch

31.

(E

xam

ple:

A c

laim

beg

inni

ng S

epte

mbe

r 27

, 20

15, u

ses

a ba

se p

erio

d of

Apr

il 1,

201

4,

thro

ugh

Mar

ch 3

1, 2

015.

)

Oct

ober

, Nov

embe

r, or

Dec

embe

r, yo

ur b

ase

peri

od is

the

12

mon

ths

endi

ng la

st Ju

ne 3

0.

(Exa

mpl

e: A

cla

im b

egin

ning

Nov

embe

r 2,

20

15, u

ses

a ba

se p

erio

d of

July

1, 2

014,

th

roug

h Ju

ne 3

0, 2

015.

)

Exce

ptio

ns: I

f you

r cla

im is

det

erm

ined

to b

e in

valid

, but

you

wer

e un

empl

oyed

and

see

king

w

ork

for 6

0 da

ys o

r mor

e in

any

qua

rter o

f you

r ba

se p

erio

d, y

ou m

ay b

e ab

le to

sub

stitu

te w

ages

pa

id in

prio

r qua

rters

.

You

may

be

entit

led

to s

ubst

itute

wag

es p

aid

in

prio

r qu

arte

rs to

eith

er v

alid

ate

your

cla

im o

r in

crea

se y

our

bene

fit a

mou

nt, i

f dur

ing

your

bas

e pe

riod

you

:

If yo

ur s

ituat

ion

fits

any

of th

e ab

ove,

incl

ude

a le

tter

and

supp

ortin

g do

cum

enta

tion

with

you

r cl

aim

form

.

Wag

e C

onti

nuat

ion.

If y

our

empl

oyer

con

tinue

s to

pay

you

wag

es w

hile

you

are

dis

able

d, y

our

DI

bene

fits

may

be

affe

cted

. DI b

enefi

ts p

lus

wag

es

cann

ot e

xcee

d yo

ur r

egul

ar w

eekl

y w

age.

DI

bene

fits

are

not a

ffect

ed b

y va

catio

n pa

y yo

u m

ay

rece

ive.

Max

imum

Ben

efits

. The

max

imum

ben

efit a

mou

nt

is 5

2 tim

es th

e w

eekl

y ra

te, b

ut n

ot m

ore

than

yo

ur to

tal b

ase

peri

od w

ages

. Exc

eptio

n: F

or

empl

oyer

s an

d se

lf-em

ploy

ed in

divi

dual

s w

ho

elec

t SD

I cov

erag

e, th

e m

axim

um b

enefi

t am

ount

is

39

times

the

wee

kly

rate

.

Add

ition

ally

, ben

efits

are

pay

able

onl

y fo

r a

limite

d pe

riod

to a

res

iden

t in

an a

lcoh

olic

reco

very

hom

e or

dru

g-fr

ee r

esid

entia

l fac

ility

that

is

bot

h lic

ense

d an

d ce

rtifi

ed b

y th

e st

ate

in w

hich

th

e fa

cilit

y is

loca

ted.

How

ever

, dis

abili

ties

rela

ted

to o

r ca

used

by

acut

e or

chr

onic

alc

ohol

ism

or

drug

abu

se, b

eing

med

ical

ly tr

eate

d, d

o no

t hav

e th

is li

mita

tion.

Preg

nanc

y. A

s w

ith a

ny m

edic

al c

ondi

tion,

you

r di

sabi

lity

perio

d be

gins

the

first

day

you

are

una

ble

to d

o yo

ur re

gula

r or c

usto

mar

y w

ork.

DI b

enefi

ts

are

base

d on

the

perio

d of

tim

e yo

ur p

hysi

cian

/pr

actit

ione

r cer

tifies

you

are

una

ble

to d

o yo

ur

regu

lar o

r cus

tom

ary

wor

k. D

o no

t sen

d in

you

r cl

aim

for p

regn

ancy

-rel

ated

DI b

enefi

ts u

ntil

the

date

you

r phy

sici

an/p

ract

ition

er c

ertifi

es y

ou a

re

disa

bled

.

NO

TE: F

or in

form

atio

n on

Pai

d Fa

mily

Lea

ve (P

FL)

bond

ing

bene

fits,

see

the

“Oth

er P

rogr

ams”

se

ctio

n of

this

bro

chur

e.

You

May

Not

be

Elig

ible

for

Ben

efits

In

sura

nce

or P

FL b

enefi

ts.

the

time

you

beco

me

disa

bled

.

crim

e.

wee

kly

rate

equ

al to

or

grea

ter

than

the

DI r

ate.

low

er r

ate

than

you

r D

I rat

e, y

ou m

ay b

e pa

id

the

diffe

renc

e.

good

cau

se).

a m

ater

ial f

act.

(A 3

0 pe

rcen

t pen

alty

may

be

asse

ssed

if b

enefi

ts a

re o

verp

aid

beca

use

you

will

fully

with

held

a m

ater

ial f

act o

r mad

e a

fals

e st

atem

ent.)

exam

inat

ion

whe

n re

ques

ted.

(Fee

s fo

r su

ch

exam

inat

ions

are

pai

d by

the

EDD

.)

The

Cal

iforn

ia U

nem

ploy

men

t Ins

uran

ce

Cod

e pr

ovid

es fo

r pe

nalti

es c

onsi

stin

g of

fine

s,

impr

ison

men

t, an

d lo

ss o

f ben

efit r

ight

s fo

r fr

aud

agai

nst t

he S

DI p

rogr

am.

Your

Rig

hts.

You

are

ent

itled

to:

that

affe

cts

your

ben

efits

.

bene

fits.

(App

eals

mus

t be

sent

to th

e D

I offi

ce

in w

ritin

g.)

Adm

inis

trat

ive

Law

Judg

e (A

LJ).

You

may

furt

her

Une

mpl

oym

ent I

nsur

ance

App

eals

Boa

rd a

nd

the

cour

ts.

ke

pt c

onfid

entia

l exc

ept f

or th

e pu

rpos

es

allo

wed

by

law

.

Your

Obl

igat

ions

. You

r re

spon

sibi

litie

s:

com

plet

ely,

and

trut

hful

ly.

to ti

me

limits

on

form

s. If

you

r cl

aim

is

subm

itted

late

and

you

bel

ieve

you

hav

e a

good

rea

son

for

bein

g la

te, y

ou s

houl

d in

clud

e a

wri

tten

expl

anat

ion

of th

e re

ason

(s) w

ith th

e fo

rm.

or h

ow to

ans

wer

it.

on le

tters

to D

I.

Con

tact

DI

e-m

ail a

t htt

ps:/

/ask

edd.

edd.

ca.g

ov

Eng

lish

1-80

0-48

0-32

87

S

pani

sh 1

-866

-658

-884

6

U.S

. mai

l add

ress

ed to

PO

Box

131

40,

Sacr

amen

to, C

A 9

5813

-314

0. If

you

do

not

have

a c

urre

nt c

laim

, you

may

wri

te to

any

D

I offi

ce. N

ote:

Do

not m

ail c

laim

form

s to

this

PO

Box

.

TTY

(tel

etyp

ewri

ter

for

deaf

, hea

ring

-im

pair

ed, a

nd s

peec

h-im

pair

ed p

erso

ns o

nly)

at

1-8

00-5

63-2

441.

In p

erso

n by

vis

iting

any

of t

he D

I offi

ces

liste

d un

der

“DI O

ffice

Loc

atio

ns.”

Oth

er P

rogr

ams

If yo

u ar

e in

jure

d on

the

job

or b

ecom

e ill

as

a re

sult

of y

our

occu

patio

n, n

otify

you

r em

ploy

er.

If yo

u ar

e ab

le a

nd a

vaila

ble

to w

ork

but

unem

ploy

ed, c

onta

ct th

e U

nem

ploy

men

t In

sura

nce

prog

ram

of t

he E

DD

thro

ugh

the

web

site

at w

ww

.edd

.ca.

gov/

unem

ploy

men

t,

or b

y ph

one

at 1

-800

-300

-561

6

(TTY

1-8

00-8

15-9

387)

.

If yo

u ne

ed h

elp

in fi

ndin

g w

ork,

job

trai

ning

, re

trai

ning

, or

othe

r se

rvic

es in

ord

er to

ret

urn

to

Cal

iforn

iaSM

form

erly

kno

wn

as O

ne-S

top

Car

eer

Cen

ters

list

ed a

t ww

w.s

ervi

celo

cato

r.org

, or

in

the

whi

te p

ages

of y

our

phon

e di

rect

ory.

If yo

ur d

isab

ility

is p

erm

anen

t or

is e

xpec

ted

to

cont

inue

for

a ye

ar o

r m

ore,

con

tact

the

U.S

. So

cial

Sec

urity

Adm

inis

trat

ion

at w

ww

.ssa

.gov

, or

by

phon

e at

1-8

00-7

72-1

213

(T

TY 1

-800

-325

-077

8).

If yo

u ta

ke ti

me

off w

ork

to c

are

for

a fa

mily

m

embe

r or

if y

ou ta

ke ti

me

off f

rom

wor

k to

bon

d w

ith a

new

chi

ld, i

nclu

ding

new

ly

adop

ted,

new

ly p

lace

d fo

ster

chi

ldre

n, o

r

thos

e of

you

r re

gist

ered

dom

estic

par

tner

, co

ntac

t the

ED

D P

FL p

rogr

am a

t w

ww

.edd

.ca.

gov/

disa

bilit

y, o

r by

pho

ne a

t 1-

877-

238-

4373

, or

thro

ugh

the

Cal

iforn

ia

Rel

ay S

ervi

ce a

t 711

.

Not

e: A

PFL

bon

ding

cla

im fo

rm w

ill b

e se

nt

auto

mat

ical

ly w

ith th

e fin

al b

enefi

t pay

men

t to

new

mot

hers

rec

eivi

ng D

I ben

efits

.

If yo

u ar

e a

vict

im o

f a c

rim

e, c

onta

ct th

e C

alifo

rnia

Vic

tim C

ompe

nsat

ion

prog

ram

at

1-80

0-77

7-92

29 (T

TY 1

-800

-735

-292

9). Y

ou

may

als

o co

ntac

t you

r co

unty

Vic

tim/W

itnes

s A

ssis

tanc

e C

ente

r.

Que

stio

ns a

bout

spo

usal

or

pare

ntal

sup

port

ob

ligat

ions

sho

uld

be d

irec

ted

to th

e di

stri

ct

cour

t ord

er.

Que

stio

ns a

bout

chi

ld s

uppo

rt o

blig

atio

ns

shou

ld b

e di

rect

ed to

the

Dep

artm

ent o

f Chi

ld

Supp

ort S

ervi

ces

at 1

-866

-901

-321

2

(TTY

1-8

66-3

99-4

096)

.

DE

2515

Rev

. 63

(11-

15) (

INTE

RN

ET)

Page

2 o

f 2

15

DE

251

1 R

ev. 1

2 (1

1-15

)

The

EDD

is an

equ

al op

portu

nity e

mplo

yer/p

rogr

am. A

uxilia

ry a

ids

and

serv

ices a

re a

vaila

ble u

pon

requ

est t

o ind

ividu

als w

ith d

isabil

ities.

Requ

ests

for s

ervic

es, a

ids, a

nd/o

r alte

rnat

e fo

rmat

s nee

d to

be

mad

e by

callin

g 1-

866-

490-

8879

(voic

e) o

r thr

ough

the

Califo

rnia

Relay

Ser

vice

at 7

11.

This

pam

phlet

is fo

r gen

eral

infor

mat

ion o

nly a

nd d

oes

not h

ave

the

forc

e an

d ef

fect

of la

w, ru

le, o

r reg

ulatio

n.

Fast

Fac

ts A

bout

P

aid

Fam

ily L

eave

The

tim

e yo

u ne

ed

for t

imes

like

thes

e.Pa

id Fa

mily

Lea

ve

Pai

d Fa

mily

Lea

veIn

Cali

forn

ia, it’

s the

law.

Be

ne ts

To a

pply

onlin

e or

for m

ore

infor

mat

ion, v

isit:

ww

w.e

dd.c

a.go

v/di

sabi

lity

Pho

ne n

umbe

r: 1-

877-

238-

4373

• P

ress

1 fo

r Eng

lish.

• P

ress

2 fo

r Spa

nish

.

•

Pre

ss 3

for C

anto

nese

.

•

Pre

ss 4

for V

ietn

ames

e.

•

Pre

ss 5

for A

rmen

ian.

• P

ress

6 fo

r Tag

alog

.

•

Pre

ss 7

for P

unja

bi.

Stat

e of

Cali

forn

ia

Pro

vides

elig

ible

work

ers w

ith p

artia

l wag

e

re

place

men

t whe

n ta

king

time

off w

ork t

o

care

for a

child

, par

ent,

pare

nt-in

-law,

gr

andp

aren

t, gr

andc

hild,

sibli

ng, s

pous

e,

or re

giste

red

dom

estic

par

tner

.

Pro

vides

cove

rage

to e

mplo

yees

who

are

co

vere

d by

SDI

(or a

volun

tary

plan

in lie

u

of

SDI

).

Offe

rs u

p to

six w

eeks

of b

enef

its in

a

12-m

onth

per

iod.

Pro

vides

ben

efits

of a

ppro

ximat

ely

55 p

erce

nt o

f los

t wag

es.

PFL

ben

efits

are

cons

idere

d ta

xable

incom

e.

Pro

vides

ben

efits

but

doe

s not

pro

vide

job

pr

otec

tion

or re

turn

righ

ts.(I

NT

ER

NE

T)

Pag

e 1

of 2

16

Pai

d Fa

mily

Lea

ve

Ben

e t

s fo

r C

alif

orni

a W

orke

rs

App

ly f

or B

ene

ts

Ther

e m

ay b

e tim

es in

the

life o

f a w

orkin

g pe

rson

whe

n th

ey n

eed

to ca

re fo

r a lo

ved

one.

Whe

ther

it’s

a wo

rking

pa

rent

bon

ding

with

a n

ewbo

rn o

r an

emplo

yee

carin

g fo

r a

serio

usly

ill ch

ild, p

aren

t, pa

rent

-in-la

w, g

rand

pare

nt,

gran

dchil

d, si

bling

, spo

use,

or r

egist

ered

dom

estic

par

tner

. Ca

liforn

ia’s P

aid F

amily

Lea

ve (P

FL) w

as cr

eate

d fo

r th

ese

times

.

Califo

rnia

leads

the

natio

n as

the

first

state

to m

ake

it ea

sier f

or e

mplo

yees

to b

alanc

e th

e de

man

ds o

f the

wo

rkpla

ce a

nd fa

mily

care

nee

ds a

t hom

e. P

FL b

enef

its

are

base

d on

the

claim

ant’s

(car

e pr

ovide

r’s) p

ast q

uar-

terly

ear

nings

. For

mor

e inf

orm

ation

rega

rding

max

imum

be

nefit

am

ount

s paid

, rea

d th

e D

isab

ility

Insu

ranc

e (D

I) an

d P

aid

Fam

ily L

eave

(PFL

) Wee

kly

Ben

e t

Am

ount

s in

Dol

lar I

ncre

men

ts fo

rm, D

E 25

89,

at w

ww

.edd

.ca.

gov/

disa

bilit

y.

A P

rogr

am B

ene

tin

g Yo

u an

d Yo

ur F

amily

For q

uest

ions a

bout

PFL

ben

efits

, ple

ase

visit

ww

w.e

dd.c

a.go

v/di

sabi

lity.

The

phon

e nu

mbe

r is l

ocat

ed o

n th

e ba

ck p

anel.

Claim

form

s sho

uld b

e m

ailed

to P

FL a

t:P.

O. B

ox 9

8931

5,W

est S

acra

men

to, C

A 95

798-

9315

Apply

for P

FL be

ne ts

onlin

e at w

ww

.edd

.ca.

gov/

disa

bilit

y.

Emplo

yers

and

phy

sician

s/pra

ctitio

ners

can

subm

it cla

im

infor

mat

ion th

roug

h SD

I Onli

ne. Y

ou m

ay a

lso fi

le us

ing a

pa

per f

orm

. To

requ

est a

claim

form

, visi

t w

ww

.edd

.ca.

gov/

disa

bilit

y.

If yo

u ar

e cu

rrent

ly re

ceivi

ng D

I pre

gnan

cy-re

lated

be

nefit

s, it

is no

t nec

essa

ry to

requ

est a

PFL

claim

form

. Cl

aim fi

ling

infor

mat

ion w

ill be

sent

thro

ugh

your

SDI

On

line

acco

unt o

r a cl

aim fo

rm w

ill be

sent

via

mail

whe

n yo

ur p

regn

ancy

-relat

ed d

isabil

ity cl

aim e

nds.

If yo

u ar

e co

vere

d by

a V

olunt

ary P

lan, c

onta

ct yo

ur

emplo

yer t

o ob

tain

infor

mat

ion a

bout

your

cove

rage

and

ins

tructi

ons o

n ho

w to

app

ly fo

r ben

efits

Con

tact

Pai

d Fa

mily

Lea

ve

Pai

d Fa

mily

Lea

ve f

or

Cal

ifor

nia

Empl

oyee

sTo

quali

fy for

PFL

bene

ts, y

ou m

ust m

eet th

e foll

owing

re

quire

ments

:

Be co

vered

by S

tate D

isabil

ity In

suran

ce (S

DI) (

or a v

olunta

ry

pla

n in l

ieu of

SDI

) and

have

earn

ed at

leas

t $30

0 in y

our

ba

se pe

riod f

rom

which

dedu

ction

s wer

e with

held.

Su

pply

medic

al inf

orma

tion s

uppo

rting y

our c

laim

that th

e

care

recip

ient h

as a

serio

us he

alth c

ondit

ion an

d req

uires

your

care

.

Subm

it you

r clai

m no

earlie

r than

nine

days

, but

no la

ter th

an

49

days

, afte

r the

rst d

ay yo

ur fam

ily ca

re lea

ve be

gan.

Pr

ovide

docu

menta

tion t

o sup

port

a clai

m for

bond

ing w

ith

a n

ew bi

ologic

al, ad

opted

, or f

oster

child

.

You m

ay ne

ed to

use u

p to t

wo w

eeks

of an

y ear

ned b

ut

un

used

vaca

tion l

eave

or pa

id tim

e off,

if req

uired

by yo

ur

em

ploye

r, prio

r to t

he in

itial re

ceipt

of be

ne ts

.

Serve

a se

ven-d

ay un

paid

waitin

g peri

od be

fore b

ene

ts are

paid

for ea

ch di

fferen

t care

recip

ient w

ithin

the 12

-mon

th pe

riod.

You m

ay no

t be e

ligibl

e for

bene

ts if:

Yo

u are

rece

iving

Disa

bility

Insu

ranc

e, Un

emplo

ymen

t

Ins

uran

ce, o

r wor

kers’

comp

ensa

tion b

ene

ts.

You a

re no

t wor

king o

r look

ing fo

r wor

k at th

e tim

e you

be

gin yo

ur fa

mily

care

leav

e.

You a

re no

t suff

ering

a los

s of w

ages

.

The n

eed f

or ca

re is

not s

uppo

rted b

y the

certi

cate

of a

tre

ating

phys

ician

/prac

tition

er.

You a

re in

custo

dy du

e to c

onvic

tion o

f a cr

ime.

You a

re en

titled

to:

Kn

ow th

e rea

son a

nd ba

sis fo

r dec

isions

affec

ting y

our b

ene

ts.

Appe

al de

cision

s abo

ut yo

ur el

igibil

ity fo

r ben

e ts.

Appe

als m

ust b

e sen

t to P

FL in

writi

ng.

A h

earin

g of y

our a

ppea

l befo

re an

Admi

nistra

tive L

aw Ju

dge.

Decis

ions m

ay be

furth

er ap

peale

d to t

he C

alifor

nia

Unem

ploym

ent In

sura

nce A

ppea

ls Bo

ard a

nd th

e cou

rts.

Pr

ivacy

-Infor

matio

n abo

ut yo

ur cl

aim w

ill be

kept

con

denti

al

ex

cept

for th

e pur

pose

s allo

wed b

y law

.

PFL b

ene

ts do

not

pro

vide

job p

rote

ction

or r

etur

n rig

hts.

Job p

rotec

tion m

ay be

prov

ided i

f you

r emp

loyer

is su

bject

to the

fede

ral F

amily

Med

ical L

eave

Act

and t

he C

alifor

nia F

amily

Ri

ghts

Act. N

otify

your

emplo

yer o

f the r

easo

n for

takin

g lea

ve

in a m

anne

r con

sisten

t with

your

comp

any’s

leav

e poli

cy.

(IN

TE

RN

ET

)P

age

2 of

2

17

For m

ore i

nfor

mat

ion,

cont

act D

FEH

toll

free a

t (8

00) 8

84-1

684

Sacr

amen

to ar

ea &

out

-of-s

tate

at (9

16) 4

78-7

200

TTY

num

ber a

t (80

0) 7

00-2

320

or v

isit o

ur W

eb si

te at

www

.dfe

h.ca

.gov

In a

ccor

danc

e with

the C

alifo

rnia

Gov

ernm

ent C

ode a

nd

ADA

requ

irem

ents,

this

publ

icatio

n ca

n be

mad

e ava

ilabl

e in

Bra

ille,

larg

e prin

t, co

mpu

ter d

isk, o

r tap

e cas

sette

as

a di

sabi

lity-

rela

ted

reas

onab

le ac

com

mod

atio

n fo

r an

indi

vidu

al w

ith a

disa

bilit

y. To

disc

uss h

ow to

rece

ive a

copy

of

this

publ

icatio

n in

an

alte

rnat

ive f

orm

at, p

lease

cont

act

DFE

H a

t the

num

bers

abo

ve.

Stat

e of C

alifo

rnia

Dep

artm

ent o

f Fai

r Em

ploy

men

t & H

ousin

g

DFE

H-1

85 (1

1/07

)

Th

e d

efi

nit

ion

of

sex

ua

l h

ara

ssm

en

t in

clu

de

s

ma

ny

fo

rms

of

off

en

siv

e b

eh

av

ior.

De

pa

rtm

en

t o

f F

air

Em

plo

ym

en

t a

nd

Ho

usi

ng

Se

xu

al

Ha

rass

me

nt

Th

e F

ac

ts A

bo

ut

Se

xu

al

Ha

rass

me

nt

The F

air E

mpl

oym

ent a

nd H

ousin

g Act

(FEH

A)

defin

es se

xual

har

assm

ent a

s har

assm

ent

base

d on

sex

or o

f a se

xual

nat

ure;

gen

der

hara

ssm

ent;

and

hara

ssm

ent b

ased

on

preg

nan-

cy, c

hild

birt

h, o

r rel

ated

med

ical

con

ditio

ns.

The d

efini

tion

of se

xual

hara

ssm

ent i

nclu

des

man

y fo

rms o

f offe

nsiv

e beh

avio

r, in

clud

ing

hara

ssm

ent o

f a p

erso

n of

the

sam

e gen

der

as th

e har

asse

r. Th

e fol

low

ing

is a p

artia

l list

of

type

s of s

exua

l har

assm

ent:

• U

nwan

ted

sexu

al ad

vanc

es

• O

fferin

g em

ploy

men

t ben

efits

in

exch

ange

for s

exua

l fav

ors

• Ac

tual

or t

hrea

tene

d re

talia

tion

• Le

erin

g; m

akin

g se

xual

ges

ture

s; or

di

splay

ing

sexu

ally

sugg

estiv

e obj

ects,

pi

ctur

es, c

arto

ons,

or p

oste

rs

• M

akin

g or

usin

g de

roga

tory

com

men

ts,

epith

ets,

slurs

, or j

okes

• Se

xual

com

men

ts in

cludi

ng g

raph

ic co

m-

men

ts ab

out a

n in

divi

dual’

s bod

y; se

xu-

ally

deg

radi

ng w

ords

use

d to

des

crib

e an

indi

vidu

al; o

r sug

gesti

ve o

r obs

cene

lette

rs,

note

s, or

invi

tatio

ns

• Ph

ysic

al to

uchi

ng o

r ass

ault,

as w

ell as

im

pedi

ng o

r blo

ckin

g m

ovem

ents

such

as a

lead

, sup

ervi

sor,

man

ager

or a

gent

;

• th

e em

ploy

er h

ad n

o kn

owle

dge

of th

e

hara

ssm

ent;

• th

ere w

as a

prog

ram

to p

reve

nt h

aras

smen

t; an

d

• on

ce aw

are o

f any

har

assm

ent,

the e

mpl

oyer

to

ok im

med

iate

and

app

ropr

iate

cor

rect

ive

actio

n to

stop

the h

aras

smen

t.

Fil

ing

a C

om

pla

int

Empl

oyee

s or j

ob ap

plica

nts w

ho b

eliev

e tha

t the

y ha

ve b

een

sexu

ally

har

asse

d m

ay fi

le a

com

plai

nt o

f di

scrim

inat

ion

with

DFE

H w

ithin

one

year

of t

he

hara

ssm

ent.

DFE

H se

rves

as a

neut

ral f

act-fi

nder

and

atte

mpt

s to

help

the p

artie

s vol

unta

rily

reso

lve d

isput

es.

If D

FEH

find

s suffi

cient

evid

ence

to es

tabl

ish th

at d

is-cr

imin

atio

n oc

curr

ed an

d se

ttlem

ent e

ffort

s fai

l, th

e D

epar

tmen

t may

file

a for

mal

accu

satio

n. Th

e acc

usa-

tion

will l

ead

to ei

ther

a pu

blic

hear

ing b

efor

e the

Fai

r Em

ploy

men

t and

Hou

sing

Com

miss

ion

or a

lawsu

it fil

ed b

y DFE

H o

n be

half

of th

e com

plai

ning

par

ty.

If th

e Com

miss

ion

finds

that

disc

rimin

atio

n ha

s oc-

curr

ed, i

t can

ord

er re

med

ies i

nclu

ding

:

• Fi

nes o

r dam

ages

for e

mot

iona

l dist

ress

fro

m ea

ch em

ploy

er o

r per

son

foun

d to

hav

e vi

olat

ed th

e law

• H

iring

or r

eins

tate

men

t

• Ba

ck p

ay o

r pro

mot

ion

• Ch

ange

s in

the p

olic

ies o

r pra

ctic

es o

f the

in

volv

ed em

ploy

er

Empl

oyee

s can

also

pur

sue t

he m

atte

r thr

ough

a

priv

ate

law

suit

in c

ivil

cour

t afte

r a c

ompl

aint

ha

s bee

n fil

ed w

ith D

FEH

and

a Rig

ht-to

-Sue

N

otic

e has

bee

n iss

ued.

For m

ore i

nfor

mat

ion,

see p

ublic

atio

n D

FEH

-159

“G

uide

for C

ompl

aina

nts a

nd R

espo

nden

ts.”

18

Th

e m

issi

on

of

the

De

pa

rtm

en

t o

f F

air

Em

plo

ym

en

t a

nd

Ho

usi

ng

is

to p

rote

ct

the

pe

op

le o

f

Ca

lifo

rnia

fro

m u

nla

wfu

l d

isc

rim

ina

tio

n i

n e

mp

loy

me

nt,

ho

usi

ng

an

d p

ub

lic

acc

om

mo

da

tio

ns,

an

d f

rom

the

pe

rpe

tra

tio

n o

f a

cts

of

ha

te v

iole

nce

.

Em

plo

ye

rs’ O

bli

ga

tio

ns

All

empl

oyer

s mus

t tak

e the

follo

win

g ac

tions

ag

ains

t har

assm

ent:

• Ta

ke al

l rea

sona

ble s

teps

to p

reve

nt

disc

rim

inat

ion

and

hara

ssm

ent f

rom

oc

curr

ing.

If h

aras

smen

t doe

s occ

ur,

take

effec

tive a

ctio

n to

stop

any

furt

her

hara

ssm

ent a

nd to

corr

ect a

ny eff

ects

of

the h

aras

smen

t.

• D

evelo

p an

d im

plem

ent a

sexu

al h

aras

s-m

ent p

reve

ntio

n po

licy

with

a pr

oced

ure

for e

mpl

oyee

s to

mak

e com

plai

nts a

nd

for t

he em

ploy

er to

inve

stiga

te co

mpl

aint

s. Po

licie

s sho

uld

incl

ude p

rovi

sions

to:

• Fu

lly in

form

the c

ompl

aina

nt o

f hi

s/he

r rig

hts a

nd an

y ob

ligat

ions

to se

-cu

re th

ose r

ight

s.

• Fu

lly an

d eff

ectiv

ely in

vesti

gate

. The i

nves

-tig

atio

n m

ust b

e tho

roug

h, o

bjec

tive,

and

com

plet

e. A

nyon

e with

info

rmat

ion

re-

gard

ing

the m

atte

r sho

uld

be in

terv

iew

ed.

A d

eter

min

atio

n m

ust b

e mad

e and

the r

e-su

lts co

mm

unic

ated

to th

e co

mpl

aina

nt,

to th

e alle

ged

hara

sser

and,

as ap

prop

riate

, to

all o

ther

s dire

ctly

conc

erne

d.

• Ta

ke p

rom

pt an

d eff

ectiv

e cor

rect

ive

actio

n if

the h

aras

smen

t alle

gatio

ns ar

e pr

oven

. The e

mpl

oyer

mus

t tak

e app

ropr

i-at

e act

ion

to st

op th

e har

assm

ent a

nd e

n-su

re it

will

not

con

tinue

. The

empl

oyer

m

ust a

lso c

omm

unic

ate

to th

e com

-

plai

nant

that

actio

n ha

s bee

n ta

ken

to st

op th

e ha

rass

men

t fro

m re

curr

ing.

Fin

ally,

appr

opria

te

steps

mus

t be t

aken

to re

med

y the

com

plai

nant

’s da

mag

es, i

f any

.

• Po

st th

e Dep

artm

ent o

f Fai

r Em

ploy

men

t and

H

ousin

g (D

FEH

) em

ploy

men

t pos

ter (

DFE

H

- 162

) in

the

wor

kpla

ce (a

vaila

ble

thro

ugh

the

DFE

H p

ublic

atio

ns li

ne [9

16] 4

78-7

201

or

Web

site

).

• D

istrib

ute a

n in

form

atio

n sh

eet o

n se

xual

ha

rass

men

t to

all e

mpl

oyee

s. A

n em

ploy

er m

ay

eith

er d

istrib

ute t

his p

amph

let (

DFE

H 1

85)

or d

evel

op a

n eq

uiva

lent

doc

umen

t tha

t mee

ts

the r

equi

rem

ents

of G

over

nmen

t Cod

e sec

tion

1295

0(b)

. This

pam

phle

t may

be d

uplic

ated

in

any

quan

tity.

How

ever

, thi

s pam

phle

t is

not t

o be

use

d in

pla

ce o

f a se

xual

har

assm

ent

prev

entio

n po

licy,

whi

ch al

l em

ploy

ers a

re

requ

ired

to h

ave.

• A

ll em

ploy

ees s

houl

d be

mad

e aw

are o

f the

se

rious

ness

of v

iolat

ions

of t

he se

xual

hara

ssm

ent

polic

y an

d m

ust b

e cau

tione

d ag

ainst

usin

g pe

er

pres

sure

to d

iscou

rage

har

assm

ent v

ictim

s fro

m co

mpl

aini

ng.

• Em

ploy

ers w

ho d

o bu

sines

s in

Calif

orni

a and

em

ploy

50

or m

ore p

art-t

ime o

r ful

l-tim

e em

ploy

ees m

ust p

rovi

de at

leas

t tw

o ho

urs o

f se

xual

har

assm

ent t

rain

ing

ever

y tw

o ye

ars

to ea

ch su

perv

isory

empl

oyee

and

to al

l new

su

perv

isory

empl

oyee

s with

in si

x m

onth

s of

thei

r ass

umpt

ion

of a

supe

rviso

ry p

ositi

on.

• A

pro

gram

to el

imin

ate s

exua

l har

assm

ent f

rom

th

e wor

kpla

ce is

not

onl

y re

quire

d by

law,

but

is

the m

ost p

ract

ical w

ay fo

r an

empl

oyer

to

avoi

d or

lim

it lia

bilit

y if

hara

ssm

ent s

houl

d oc

cur d

espi

te p

reve

ntiv

e effo

rts.

Em

plo

ye

r L

iab

ilit

y

All e

mpl

oyer

s, re

gard

less o

f the

num

ber o

f em

ploy

ees,

are c

over

ed b

y the

har

assm

ent s

ectio

n of

the F

EHA

. Em

ploy

ers a

re g

ener

ally

liab

le fo

r har

assm

ent b

y th

eir su

perv

isors

or a

gent

s. H

aras

sers

, inc

ludi

ng b

oth

supe

rviso

ry an

d no

n-su

perv

isory

per

sonn

el, m

ay b

e he

ld p

erso

nally

liab

le fo

r har

assin

g an

empl

oyee

or

cow

orke

r or f

or ai

ding

and

abet

ting

hara

ssm

ent.

Add

ition

ally

, the

law

requ

ires

em

ploy

ers t

o ta

ke

“all

reas

onab

le ste

ps to

pre

vent

har

assm

ent f

rom

oc

curr

ing.

” If a

n em

ploy

er h

as fa

iled

to ta

ke su

ch

prev

entiv

e mea

sure

s, th

at em

ploy

er ca

n be

hel

d li-

able

for t

he h

aras

smen

t. A

vic

tim m

ay b

e ent

itled

to

dam

ages

, eve

n th

ough

no

empl

oym

ent o

ppor

tuni

ty

has b

een

deni

ed an

d th

ere i

s no

actu

al lo

ss o

f pay

or

bene

fits.

In ad

ditio

n, if

an em

ploy

er k

now

s or s

houl

d ha

ve

know

n th

at a

non-

empl

oyee

(e.g

. clie

nt o

r cus

tom

-er

) has

sexu

ally

har

asse

d an

empl

oyee

, app

lican

t, or

pe

rson

pro

vidi

ng se

rvice

s for

the e

mpl

oyer

and

fails

to

take

imm

edia

te a

nd a

ppro

pria

te co

rrec

tive a

c-tio

n, th

e em

ploy

er m

ay b

e hel

d lia

ble f

or th

e act

ions

of

the n

on-e

mpl

oyee

.

An

empl

oyer

mig

ht av

oid

liabi

lity

if

• th

e har

asse

r is n

ot in

a po

sitio

n of

auth

ority

,

19

FOR CALIFORNIA ONLY Policy Against Harassment and Discrimination

TriNet (“TriNet”) and the Company are committed to creating a respectful, courteous work environment free of unlawful discrimination and harassment of any kind, and we are committed to taking all reasonable steps to prevent it and address it. We prohibit discrimination and harassment against employees, applicants for employment, individuals providing services in the workplace pursuant to a contract, interns, volunteers based on their actual or perceived race, religious creed, color, national origin, ancestry, physical disability, mental disability, medical condition, genetic information, marital status, sex, gender, gender identity, gender expression, age, sexual orientation, Civil Air Patrol status, military and veteran status, and any other consideration protected by federal, state or local law, by any employee, contractor, vendor, customer, or visitor. In addition to any disciplinary action we may take, up to and including termination of employment, offenders may also be personally liable, in the event of litigation, for damages and attorney’s fees and other costs of litigation.

For purposes of this policy, discrimination on the basis of "national origin" also includes discrimination against an individual because that person holds or presents the California driver's license issued to those who cannot document their lawful presence in the United States. An employee's or applicant for employment's immigration status will not be considered for any employment purpose except as necessary to comply with federal, state or local law. Our commitment to equal employment opportunity applies to all persons involved in our operations and prohibits unlawful discrimination and harassment by any employee (including supervisors and co-workers), agent, client, customer, or vendor.

Except where otherwise indicated, the term “harassment," as used in this policy, refers to behavior that is related to any characteristic protected under applicable law and that is personally offensive, intimidating, or hostile, or interferes with work performance, regardless of whether it rises to the level of violating the law. In other words, this policy is stricter than the law, in that this policy defines harassment more broadly than does the law.

This policy applies to all persons involved in our operations, including coworkers, supervisors, managers, temporary or seasonal workers, agents, clients, vendors, customers, or any other third party interacting with the Company (“third parties”) and prohibits proscribed harassing conduct by any employee or third party of the Company, including nonsupervisory employees, supervisors and managers. If such harassment occurs on the Company’s premises or is directed toward an employee or a third party interacting with the Company, the procedures in this policy should be followed.

What is Sexual Harassment?

Under various state and federal laws, sexual harassment includes, but is not limited to, making unwanted sexual advances and requests for sexual favors where:

• Submission to such conduct or communication is either explicitly or implicitly made a term or condition of an individual’s employment; or

20

• Submission to or rejection of such conduct or communication by an individual is used as a basis for employment decisions affecting such individual; or

• Such conduct or communication has the purpose or effect of unreasonably interfering with an individual’s work performance or creates and/or perpetuates an intimidating, hostile, or offensive work environment.

• As defined by law, sexual harassment can also take the form of other unwelcome conduct or communication that has the purpose or effect of unreasonably interfering with an individual’s work performance or creates and/or perpetuates an intimidating, hostile, or offensive work environment. Such other conduct or communication sometimes takes the form of verbal abuse of a sexual nature, unwanted touching, leering, sexual gestures, a display of sexually suggestive objects or images, sexually explicit or offensive jokes, stories, cartoons, nicknames, slurs, epithets, and other communications of a sexual nature.

What Are Other Kinds of Harassment?

In addition to sexual harassment, TriNet and the Company prohibit all other harassment based on race, religious creed, color, national origin, ancestry, physical disability, mental disability, medical condition, genetic information, marital status, gender, gender identity, gender expression, age, sexual orientation, Civil Air Patrol status, military and veteran status, or any other characteristic protected by federal, state, or local law.

Forms of Harassment

Harassment may take many forms, including:

• Verbal. Epithets; derogatory comments, slurs, or name-calling; inappropriate jokes, emails or any other form of written communication, comments, noises, or remarks; repeated requests for dates, threats, propositions, unwelcome and unwanted correspondence, phone calls, and gifts; or other unwelcome attention.

• Physical. Assault; impeding or blocking movement; physical interference with normal work or movement; unwanted and unwarranted physical contact, such as touching, pinching, patting, grabbing, brushing against, or poking another employee’s body.

• Visual. Inappropriate images (whether in photographs, posters, cartoons, drawings, paintings or other forms of imagery); displaying inappropriate images, writings or objects; staring at or directing attention to an employee’s anatomy; leering; sexually oriented or suggestive gestures.

• Cyberstalking. Harassment using electronic communication, such as e-mail or instant messaging (IM), or messages posted to a website, blog, or discussion group.

These kinds of behavior can occur in one-on-one interactions or in group settings and can involve a co-worker, manager, vendor, customer, visitor, or agent of the Company. Sexual harassment can also occur in the context of a relationship that was once consensual but has

21

changed so that the behavior is no longer welcome by one party. It is impossible to specify every action or all words that could be interpreted as harassment. The examples listed above are not meant to be a complete list of objectionable behavior. Make a point of paying attention to others’ reactions and stated requests and preferences, respecting their wishes, and treating them in a professional manner, regardless of gender, race, religion, nationality, age, sexual orientation, sexual identity or expression, or other protected characteristic.

An employee may be liable for harassment based on sex even if the alleged harassing conduct was not motivated by sexual desire. An employee who engages in unlawful harassment may be personally liable for harassment even if the Company had no knowledge of such conduct.

Abusive Conduct Prevention

It is expected that persons in the workplace perform their jobs productively as assigned, and in a manner that meets all of managements’ expectations, during working times, and that they refrain from any malicious, patently offensive or abusive conduct including but not limited to conduct that a reasonable person would find offensive based on any of the protected characteristics described above. Examples of abusive conduct include repeated infliction of verbal abuse, such as the use of malicious, derogatory remarks, insults, and epithets, verbal or physical conduct that a reasonable person would find threatening, intimidating, or humiliating, or the intentional sabotage or undermining of a person's work performance.

Reporting and Investigating Harassment

If you believe anyone is harassing you or another individual in the workplace, we encourage you, if comfortable doing so, to tell the harasser in clear language that the behaviors or advances are unwelcome or unwanted and must stop. The individual may not realize the behavior is offensive and a simple communication may effectively end the behavior. However, if you are not comfortable engaging in such communication or the behavior does not stop following such communication, you should immediately report your concern to your manager, any other Company manager or official, your TriNet HR Representative or the TriNet Employee Solution Center. Report the facts of the incident, including what happened, when, where, how often, and the names of the accused and any witnesses. Supervisors and Managers should immediately report any suspected incidents of harassment of others, including any complaint of harassment made by another employee, to a TriNet HR Representative.

All harassment claims will be investigated in a fair, timely, objective, and thorough manner that provides all parties due process and reaches reasonable conclusions based on the evidence collected. Such investigations will be conducted as confidentially as possible. All employees are expected to cooperate fully in any investigation. Upon completion of the investigation, the Company will communicate its conclusion as soon as practicable. If it is determined that prohibited harassment has occurred, the appropriate corrective action, up to and including termination of employment of the offending employee, will be taken along with any additional steps necessary to prevent further violations of this policy.

22

The federal Equal Employment Opportunity Commission (EEOC) and the California Department of Fair Employment and Housing (DFEH) will accept and investigate charges of unlawful discrimination or harassment at no charge to the complaining party. Information may be located by visiting the agency website at www.eeoc.gov or www.dfeh.ca.gov.

Protection Against Retaliation

TriNet, the Company, and the law do not tolerate any form of retaliation against any employee who opposes discrimination or prohibited harassment, makes a complaint, or participates in any manner in an internal investigation or an investigation, proceeding, or hearing conducted by a state or federal agency or court. If you believe that you have experienced or witnessed retaliation, you should immediately report your concern to your manager, any other manager or officer, a TriNet HR Representative or the TriNet Employee Solution Center. Any employee who engages in retaliation will be subject to disciplinary action, up to and including termination of employment, as well as possible legal consequences.

23

ACKNOWLEDGEMENT & RECEIPT OF

COMPANY POLICY AGAINST HARASSMENT AND DISCRIMINATION

I acknowledge that I have received, read, and understand the Company’s Policy Against Harassment and Discrimination. I agree to abide by and be bound by the rules, provisions and standards set forth in this policy. I further acknowledge that the Company reserves the right to revise, delete and add to the provisions of the Policy Against Harassment and Discrimination at any time.

_______________________________________________

Employee Signature

_______________________________________________

Print Name

_______________________________________________

Date

[TO BE PLACED IN EMPLOYEE'S PERSONNEL FILE]

24

Updated March 2015

Trinet SOI

Employee Time of Hire MPN Notice

MPN Implementation Notice

Your employer has a Medical Provider Network (MPN) to treat work-related injuries. Unless you have a properly pre-designated physician or medical group prior to an injury, any new work-related injuries arising on or after 2012 will be treated by providers in the Medical Provider Network, under MPN ID No.: 06-0383030-1941. You may obtain more information about your rights and obligations within the MPN from the Employee Guide to MPN by requesting a copy of the complete guide from your employer. Attachments:

- Predesignation form English - Predesignation form Spanish

Important Information about Medical Care if you have a Work-Related Injury or Illness

TriNet SOI

25

TIME OF HIRE PAMPHLET

This pamphlet, or a similar one that has been approved by the Administrative Director, must be given to all newly hired employees in the State of California. Employers and claims administrators may use the content of this document and put their logos and additional information on it. The content of this pamphlet applies to all industrial injuries that occur on or after January 1, 2013.

WHAT IS WORKERS’ COMPENSATION?

If you get hurt on the job, your employer is required by law to pay for workers’ compensation benefits. You could get hurt by:

One event at work. Examples: hurting your back in a fall, getting burned by a chemical that splashes on your skin, getting hurt in a car accident while making deliveries.

—or—Repeated exposures at work. Examples: hurting your wrist from using vibrating tools, losing your hearing because of constant loud noise.

—or—Workplace crime. Examples: you get hurt in a store robbery, physically attacked by an unhappy customer.

Discrimination is illegal

It is illegal under Labor Code section 132a for your employer to punish or fire you because you:File a workers’ compensation claimIntend to file a workers’ compensation claimSettle a workers’ compensation claimTestify or intend to testify for another injured worker.

If it is found that your employer discriminated against you, he or she may be ordered to returnyou to your job. Your employer may also be made to pay for lost wages, increased workers’ compensation benefits, and costs and expenses set by state law.

WHAT ARE THE BENEFITS?

Medical care: Paid for by your employer to help you recover from an injury or illnesscaused by work. Doctor visits, hospital services, physical therapy, lab tests and x-rays are some of the medical services that may be provided. These services should be necessary to treat your injury. There are limits on some services such as physical and occupational therapy and chiropractic care.

July 2014

26

Temporary disability benefits: Payments if you lose wages because your injury prevents you from doing your usual job while recovering. The amount you may get is up to two-thirds of your wages. There are minimum and maximum payment limits set by state law. You will be paid every two weeks if you are eligible. For most injuries, payments may not exceed 104 weeks within five years from your date of injury. Temporary disability (TD) stops when you return to work, or when the doctor releases you for work, or says your injury has improved as much as it’s going to.

Permanent disability benefits: Payments if you don’t recover completely. You will bepaid every two weeks if you are eligible. There are minimum and maximum weekly payment rates established by state law. The amount of payment is based on:

o Your doctor’s medical reportso Your ageo Your occupation

Supplemental job displacement benefits: This is a voucher for up to $6,000 that you can use for retraining or skill enhancement at an approved school, books, tools, licenses or certification fees, or other resources to help you find a new job. You are eligible for this voucher if:

o You have a permanent disability.o Your employer does not offer regular, modified, or alternative work, within 60

days after the claims administrator receives a doctor’s report saying you have made a maximum medical recovery.

Death benefits: Payments to your spouse, children or other dependents if you die from a job injury or illness. The amount of payment is based on the number of dependents. The benefit is paid every two weeks at a rate of at least $224 per week. In addition, workers’ compensation provides a burial allowance.

OTHER BENEFITS

You may file a claim with the Employment Development Department (EDD) to get state disability benefits when workers’ compensation benefits are delayed, denied, or have ended. There are time restrictions so for more information contact the local office of EDD or go to their web site www.edd.ca.gov.

If your injury results in a permanent disability (PD) and the state determines that your PD benefit is disproportionately low compared to your earning loss, you may qualify for additional money from the Department of Industrial Relation’s special earnings loss supplement program also known as the return to work program. If you have questions or think you qualify, contact the Information & Assistance Unit by going to www.dwc.ca.gov and looking under “Workers’

July 2014

27

Compensation programs and units” for the “Information & Assistance Unit” link or visit the DIR web site at www.dir.ca.gov.

Workers’ compensation fraud is a crimeAny person who makes or causes to be made any knowingly false statement in order to obtain or deny workers’ compensation benefits or payments is guilty of a felony. If convicted, the person will have to pay fines up to $150,000 and/or serve up to five years in jail.

WHAT SHOULD I DO IF I HAVE AN INJURY?

Report your injury to your employerTell your supervisor right away no matter how slight the injury may be. Don’t delay – there are time limits. You could lose your right to benefits if your employer does not learn of your injury within 30 days. If your injury or illness is one that develops over time, report it as soon as you learn it was caused by your job.

If you cannot report to the employer or don’t hear from the claims administrator after you have reported your injury, contact the claims administrator yourself.

Workers’ compensation insurance company or if employer is self-insured, person responsible for handling the claim is:

__________________________________________________

Address: ___________________________________________________

Phone: ____________________________________________________.

You may be able to find the name of your employer’s workers’ compensation insurer at www.caworkcompcoverage.com. If no coverage exists or coverage has expired, contact theDivision of Labor Standards Enforcement at www.dir.ca.gov/DLSE as all employees must be covered by law.

Get emergency treatment if neededIf it’s a medical emergency, go to an emergency room right away. Tell the medical provider who treats you that your injury is job related. Your employer may tell you where to go for follow uptreatment.

July 2014

28

Emergency telephone number: Call 911 for an ambulance, fire department or police. For non-emergency medical care, contact your employer, the workers’ compensation claims administrator or go to this facility:

_________________________________________________________.

Fill out DWC 1 claim form and give it to your employer Your employer must give you a DWC 1 claim form within one working day after learning about your injury or illness. Complete the employee portion, sign and give it back to your employer. Your employer will then file your claim with the claims administrator. Your employer must authorize treatment within one working day of receiving the DWC 1 claim form.

If the injury is from repeated exposures, you have one year from when you realized your injury was job related to file a claim.

In either case, you may receive up to $10,000 in employer-paid medical care until your claim is either accepted or denied. The claims administrator has up to 90 days to decide whether to accept or deny your claim. Otherwise your case is presumed payable.

Your employer or the claims administrator will send you “benefit notices” that will advise you ofthe status of your claim.

MORE ABOUT MEDICAL CARE

What is a Primary Treating Physician (PTP)?This is the doctor with overall responsibility for treating your injury or illness. He or she may be:

The doctor you name in writing before you get hurt on the jobA doctor from the medical provider network (MPN)The doctor chosen by your employer during the first 30 days of injury if your employer does not have an MPN orThe doctor you chose after the first 30 days if your employer does not have an MPN.

What is a Medical Provider Network (MPN)?An MPN is a select group of health care providers who treat injured workers. Check with your employer to see if they are using an MPN.

If you have not named a doctor before you get hurt and your employer is using an MPN, you will see an MPN doctor. After your first visit, you are free to choose another doctor from the MPN list.

What is Predesignation?Predesignation is when you name your regular doctor to treat you if you get hurt on the job. The doctor must be a medical doctor (M.D.), doctor of osteopathic medicine (D.O.) or a medical group with an M.D. or D.O. You must name your doctor in writing before you get hurt or become ill. July 2014

29

You may predesignate a doctor if you have health care coverage for non-work injuries and illnesses. The doctor must have:

Treated you Maintained your medical history and records before your injury and Agreed to treat you for a work-related injury or illness before you get hurt or become ill.

You may use the “predesignation of personal physician” form included with this pamphlet. After you fill in the form, be sure to give it to your employer.

If your employer does not have an approved MPN, you may name your chiropractor or acupuncturist to treat you for work related injuries. The notice of personal chiropractor or acupuncturist must be in writing before you get hurt. You may use the form included in this pamphlet. After you fill in the form, be sure to give it to your employer.

With some exceptions, state law does not allow a chiropractor to continue as your treating physician after 24 visits. Once you have received 24 chiropractic visits, if you still require medical treatment, you will have to select a new physician who is not a chiropractor. The term “chiropractic visit” means any chiropractic office visit, regardless of whether the services performed involve chiropractic manipulation or are limited to evaluation and management.

Exceptions to the prohibition on a chiropractor continuing as your treating physician after 24 visits include postsurgical physical medicine visits prescribed by the surgeon, or physician designated by the surgeon, under the postsurgical component of the Division of Workers’ Compensation’s Medical Treatment Utilization Schedule, or if your employer has authorized additional visits in writing.

WHAT IF THERE IS A PROBLEM?

If you have a concern, speak up. Talk to your employer or the claims administrator handling your claim and try to solve the problem. If this doesn’t work, get help by trying the following:

Contact the Division of Workers’ Compensation (DWC) Information and Assistance (I&A) UnitAll 24 DWC offices throughout the state provide information and assistance on rights, benefits and obligations under California's workers' compensation laws. I&A officers help resolve disputeswithout formal proceedings. Their goal is to get you full and timely benefits. Their services are free.

To contact the nearest I&A Unit, go to www.dwc.ca.gov and under “Workers’ Compensation programs and units”, click on “Information & Assistance Unit.” At this site you will find fact sheets, guides and information to help you.

The nearest I&A Unit is located at:

Address:

Phone number: ________________________________________________.

July 2014

30

Consult with an attorneyMost attorneys offer one free consultation. If you decide to hire an attorney, his or her fees may be taken out of some of your benefits. For names of workers’ compensation attorneys, call the State Bar of California at (415) 538-2120 or go to their website at www.californiaspecialist.org.You may get a list of attorneys from your local I&A Unit or look in the yellow pages.

WarningYour employer may not pay workers’ compensation benefits if you get hurt in a voluntary off-duty recreational, social or athletic activity that is not part of your work-related duties.

Additional rightsYou may also have other rights under the Americans with Disabilities Act (ADA) or the Fair Employment and Housing Act (FEHA). For additional information, contact FEHA at (800) 884-1684 or the Equal Employment Opportunity Commission (EEOC) at (800) 669-4000.

The information contained in this pamphlet conforms to the informational requirements found in Labor Code sections 3551 and 3553 and California Code of Regulation, Title 8, sections 9880 and 9883. This document is approved by the Division of Workers’ Compensation administrative director.

Revised 6/17/14 and effective for dates of injuries on or after 1/1/13

July 2014

31

PREDESIGNATION OF PERSONAL PHYSICIANIn the event you sustain an injury or illness related to your employment, you may be treated for such injury or illness by your personal medical doctor (M.D.), doctor of osteopathic medicine (D.O.) or medical group if:

on the date of your work injury you have health care coverage for injuries or illnesses that are not workrelated;the doctor is your regular physician, who shall be either a physician who has limited his or her practice ofmedicine to general practice or who is a board-certified or board-eligible internist, pediatrician,obstetrician-gynecologist, or family practitioner, and has previously directed your medical treatment, andretains your medical records;your “personal physician” may be a medical group if it is a single corporation or partnership composed oflicensed doctors of medicine or osteopathy, which operates an integrated multispecialty medical groupproviding comprehensive medical services predominantly for nonoccupational illnesses and injuries;prior to the injury your doctor agrees to treat you for work injuries or illnesses;prior to the injury you provided your employer the following in writing: (1) notice that you want yourpersonal doctor to treat you for a work-related injury or illness, and (2) your personal doctor's name andbusiness address.

You may use this form to notify your employer if you wish to have your personal medical doctor or a doctor of osteopathic medicine treat you for a work-related injury or illness and the above requirements are met.

NOTICE OF PREDESIGNATION OF PERSONAL PHYSICIAN Employee: Complete this section.

To: ____________________________ (name of employer) If I have a work-related injury or illness, I choose to be treated by:_________________________________________________________________ (name of doctor)(M.D., D.O., or medical group)_________________________________________________________________ (street address, city, state, ZIP)

__________________________________________________ (telephone number)

Employee Name (please print): _____________________________________________________________________________________________

Employee's Address:_____________________________________________________________________________________________

Name of Insurance Company, Plan, or Fund providing health coverage for nonoccupational injuries or illnesses:

Employee's Signature ________________________________Date: __________

Physician: I agree to this Predesignation:

Signature: _________________ ___________________________Date: __________(Physician or Designated Employee of the Physician or Medical Group)

The physician is not required to sign this form, however, if the physician or designated employee of the physician or medical group does not sign, other documentation of the physician's agreement to be predesignated will be required pursuant to Title 8, California Code of Regulations, section 9780.1(a)(3).

Title 8, California Code of Regulations, section 9783.

Predesignation of Personal Physician; Reporting Duties of the Primary Treating Physician Regulations 8 C.C.R. section 9780, et seq. (Approved 02/12/2014)

32

§ 9783.1. DWC Form 9783.1 Notice of Personal Chiropractor or Personal Acupuncturist.

NOTICE OF PERSONAL CHIROPRACTOR OR PERSONAL ACUPUNCTURIST

If your employer or your employer's insurer does not have a Medical Provider Network, you may be able to change your treating physician to your personal chiropractor or acupuncturist following a work-related injury or illness. In order to be eligible to make this change, you must give your employer the name and business address of a personalchiropractor or acupuncturist in writing prior to the injury or illness. Your claims administrator generally has the right to select your treating physician within the first 30 days after your employer knows of your injury or illness. After your claims administrator has initiated your treatment with another doctor during this period, you may then, upon request, have your treatment transferred to your personal chiropractor or acupuncturist.

NOTE: If your date of injury is January 1, 2004 or later, a chiropractor cannot be your treating physician after you have received 24 chiropractic visits unless your employer has authorized additional visits in writing. The term “chiropractic visit” means any chiropractic office visit, regardless of whether the services performed involve chiropractic manipulation or are limited to evaluation and management. Once you have received 24 chiropractic visits, if you still require medical treatment, you will have to select a new physician who is not a chiropractor. This prohibition shall not apply to visits for postsurgical physical medicine visits prescribed by the surgeon, or physician designated by the surgeon, under the postsurgical component of the Division of Workers’ Compensation’s Medical Treatment Utilization Schedule.

You may use this form to notify your employer of your personal chiropractor or acupuncturist.

Your Chiropractor or Acupuncturist's Information:

__________________________________________________________________________________________(name of chiropractor or acupuncturist)

__________________________________________________________________________________________(street address, city, state, zip code)

__________________________________________________________________________________________(telephone number)

Employee Name (please print):

__________________________________________________________________________________________

Employee's Address:

__________________________________________________________________________________________

Employee's Signature ___________________________ Date: _________

July 2014