Reporting Injuries
If you are injured at work, you must take the following steps immediately in order to qualify for Workers’ Compensation benefits:
- Report the injury to your supervisor or Yazmin Perez – 408-924-2155
- If you must seek medical attention first, notify your supervisor or Yazmin Perez @ 408-924-2155 as soon as possible.
- Seek medical attention
Your supervisor must then take the following steps:
- Complete the Employer’s Report of Occupational Injury or Illness [pdf]
- Write the description of the accident using the employee’s own account
- Give you (the employee) a copy of the Workers’ Compensation Claim Form (DWC 1) and Notice of Potential Eligibility [pdf]
- Sign and submit both forms via DocuSign to Yazmin Perez when complete.
Additional Information
- Seek Medical Attention
- Prescribed Medications
- Industrial Disability Leave
- Workers' Comp Forms and Policies
- Report Unsafe Working Conditions
For additional information contact up-leaves@xfmlsp.com.
