Skip to the content
Home
About Us
Employee Discounts
Contact Us
Resourceful Forms
Timekeeping
Call US (951) 281-8011
Home
About Us
Employee Discounts
Contact Us
Resourceful Forms
Timekeeping
Home
About Us
Employee Discounts
Contact Us
Resourceful Forms
Timekeeping
Workers’ Compensation Claim Intake Form
Please enable JavaScript in your browser to complete this form.
Section 1: Employee Details
Employee Name
*
First
Last
Job Location
Employee Position
Hourly or Salary Rate
Hourly
Salary
Hourly Rate
Example: $16.50
Salary Rate
Example: $75,000
Date of Hire
Date of Termination
Section 2: Job Location Details
Legal Name
DBA (Doing Business As)
FEIN
WC Carrier
Policy Period Start Date
Policy Period End Date
Policy Number
Section 3: Document Upload
Document Upload
*
Drag & Drop Files,
Choose Files to Upload
You can upload up to 10 files.
Upload I-9, W-4, Payroll Journal
Submit
Mutual Arbitration Agreement
Please enable JavaScript in your browser to complete this form.
I
*
First
Last
Date
*
Acknowledgement
*
I acknowledge that I have read and that I understand the Arbitration of Disputes policy. I further understand that the agreement to arbitrate may not be waived without a written document signed by both myself and the Company. If for any reason the Federal Arbitration Act (FAA) is deemed inapplicable to this Mutual Arbitration Policy, then and only then Arbitration will be governed by the California Arbitration Act, Code of Civil Procedure section 1280 et. seq. In such circumstances, I have the right to refuse to proceed to Arbitration. There will be no adverse consequences if I choose not to agree to Arbitrate any employment-related disputes as outlined above under the California Arbitration Act. If the Federal Arbitration Act (FAA) is deemed to be inapplicable and I still desire to proceed to Arbitration, If the Federal Arbitration Act (FAA) is deemed inapplicable, I AGREE to proceed to Arbitration
I acknowledge that I have read and that I understand the Arbitration of Disputes policy. I further understand that the agreement to arbitrate may not be waived without a written document signed by both myself and the Company. If for any reason the Federal Arbitration Act (FAA) is deemed inapplicable to this Mutual Arbitration Policy, then and only then Arbitration will be governed by the California Arbitration Act, Code of Civil Procedure section 1280 et. seq. In such circumstances, I have the right to refuse to proceed to Arbitration. There will be no adverse consequences if I choose not to agree to Arbitrate any employment-related disputes as outlined above under the California Arbitration Act. If the Federal Arbitration Act (FAA) is deemed to be inapplicable and I still desire to proceed to Arbitration, If the Federal Arbitration Act (FAA) is deemed inapplicable, I AGREE to proceed to Arbitration
Signature
*
Clear Signature
For mobile phones, and tablets use your finger to draw your signature.
Submit
CLOSE
