Professional Documents
Culture Documents
COMPANY NAME
ADDRESS
TELEPHONE NUMBER
NAME OF EMPLOYEE
EMPLOYEES TITLE
DATE OF ACCIDENT
DATE HIRED
PARTIAL DAYS LOST FROM WORK (Specify Dates and Number of Hours) :
Do not indicate whether salary was continued or not since California Law denies
a negligent party credit for wage continuation or disability benefits.
COMMENTS :
DATED :
SIGNATURE
PRINT NAME
TITLE