Initial Report Or Claim Form. This is a California form and can be use in DLSE Forms Workers Comp.
Tags: Initial Report Or Claim, DLSE-1, California Workers Comp, DLSE Forms
LABOR COMMISSIONER, STATE OF CALIFORNIA DEPARTMENT OF INDUSTRIAL RELATIONS – DIVISION OF LABOR STANDARDS ENFORCEMENT Initial Report or Claim FOR OFFICE USE ONLY Office: Taken by: PLEASE PRINT OR TYPE ALL INFORMATION Date filed: Case #: SIC #: Refer to the accompanying Guide to assist you in filling out this form. RCI Complaint: YES Action: NO PRELIM IN ARY Q U ESTIO N S 1. Is your claim about a public works project? [If your answer is “YES,” STOP here, DO NOT FILL OUT THIS FORM, and fill out the “PW-1” claim form instead. If your answer is “NO,” proceed with this form.] 2. Have you filed a retaliation complaint against your employer with the Labor Commissioner? YES, on: _________/________/________ Month Day Year NO [ If you have been retaliated against, you may file a retaliation complaint by filling out another form, “DLSE FORM 205.”] 3. Is there a union contract covering your employment? YES [If “YES,” attach a copy of the Collective Bargaining Agreement.] NO 4. Are other employees also filing wage claims against your employer? YES NO I DON’T KNOW Part 1: LAN G U AG E ASSISTAN CE & REPRESEN TATIO N 5a. Do you need an interpreter? YES NO 5b. If you checked “YES” to Box 5a, enter the language needed 6a. If you are being assisted with your claim by a lawyer or other advocate, enter your ADVOCATE’S NAME 6b. ADVOCATE’S PHONE and ORGANIZATION ( CITY 6c. Your ADVOCATE’S MAILING ADDRESS (Number, Street, Floor, Suite) ) STATE ZIP CODE Pa rt 2: Y O U R IN FO RM ATIO N a 7. Your FIRST NAME 8. Your LAST NAME 9. HOME PHONE 10. OTHER PHONE ( ( ) ) CITY 12. Your MAILING ADDRESS (Street Number, Street Name, Apartment Number) 11. BIRTH DATE STATE ZIP CODE Part 3: C LAIM FILED AG AIN ST (EM PLO YER IN FO RM ATIO N ) 13. EMPLOYER / BUSINESS NAME(S) 14. EMPLOYER’S VEHICLE LICENSE PLATE # 15. EMPLOYER PHONE ( ) 16. ADDRESS of EMPLOYER / BUSINESS (Street Number, Street Name, Floor, Suite): CITY STATE ZIP CODE 17. ADDRESS where you worked, if different from Box 16 (Number, Street, Floor, Suite): CITY STATE ZIP CODE 18. NAME of PERSON IN CHARGE (First Name, Last Name) 20. TYPE OF BUSINESS 21. TYPE OF WORK PERFORMED 24. Check which box describes your employer, if you know: DLSE FORM 1 / WAGE ADJUDICATION (REV. 7/2012) 19. JOB TITLE / POSITION of PERSON IN CHARGE 22. TOTAL NUMBER OF EMPLOYEES CORPORATION 23. INDIVIDUAL EMPLOYER STILL IN BUSINESS? YES NO PARTNERSHIP DON’T KNOW LLC (Page 1 of 3) American LegalNet, Inc. www.FormsWorkFlow.com LLP PRINT YOUR NAME: ________________________________________ P art 4: FIN AL W AG ES / BO U N CED CH ECK S 25. DATE OF HIRE 26. Check which box applies to you: ____/____/_____ Month Day Still working for employer QUIT on Year ___ /___/____ Month Other (specify): 27a. If you QUIT, did you give 72 hours notice before quitting? Day DISCHARGED on ___/___/____ Year Month Day Year _____________________________________________________________________________________ 27b. If you QUIT, have you received your final payment of wages including all wages owed? YES, on: YES _______ /_______/_________ Month Day Year NO NO 28. If you were DISCHARGED, have you received your final payment of wages including all wages owed? YES, on: _______ /_______/_________ Month Day Year NO 29b. If paid by check, did any of your paychecks “bounce” 29a. How were your wages paid? BY CHECK BY CASH (for example, paycheck could not be cashed because employer has insufficient funds)? BY BOTH CASH & CHECK OTHER: __________________________________________ YES NO Part 5: H O U RS YO U TYPICALLY W O RK ED 30. Check which box applies: My work hours and days of work were usually the same each week that I worked. My work hours and/or days of work varied per week or were irregular. If you checked this box and you are claiming unpaid wages or meal and rest period violations, you should also fill out and submit the DLSE FORM 55. 31. If your work hours and days of work were usually the same each week, give your BEST ESTIMATE below of the hours you usually worked and any time you took for a duty-free meal period during your TYPICAL workweek. DO NOT fill this out if your work hours were too irregular to estimate a typical or average workweek (instead fill out the DLSE Form 55). TIME WORK STARTED TIME WORK ENDED am am DAY 1 of your workweek: _______ _______ _______ pm _______ am pm _______ am am 1st shift ended at 2nd shift started at pm _______ pm _______ pm _______ am am am am pm am pm 1st shift ended at _______ pm _______ pm _______ pm _______ pm _______ am am am am _______ pm _______ pm _______ pm _______ pm _______ pm am pm am _______ pm 1st shift ended at _______ am am am am 2nd shift started at am pm am 1st shift ended at _______ pm _______ pm _______ pm _______ pm _______ pm _______ am am am am am pm _______ am am pm 1st shift ended at _______ pm _______ pm _______ pm _______ pm _______ pm _______ am am am am am pm _______ am am pm 1st shift ended at _______ pm _______ pm _______ pm _______ pm _______ pm _______ am am am am am pm _______ am am pm 1st shift ended at _______ pm _______ DLSE FORM 1 / WAGE ADJUDICATION (REV. 7/2012) pm _______ pm _______ pm _______ pm _______ pm 2nd shift started at am _______ pm 2nd shift started at am _______ pm 2nd shift started at am _______ pm 2nd shift started at am _______ pm pm _______ am pm 2nd shift started at am DAY 7 of your workweek: am ONLY IF YOU WORKED A SPLIT SHIFT: _______ DAY 6 of your workweek: am 2nd MEAL END TIME (if applicable) am DAY 5 of your workweek: pm am DAY 4 of your workweek: am 2nd MEAL START TIME (if applicable) _______ DAY 3 of your workweek: 1st MEAL END TIME (if applicable) am DAY 2 of your workweek: 1st MEAL START TIME (if applicable) am pm _______ pm _______ (CONTINUED – Page 2 of 3) American LegalNet, Inc. www.FormsWorkFlow.com pm Part 6: PAYM EN T O F W AG ES 32. Were you paid or promised a FIXED amount of wages per pay period, no matter how many hours you worked (for example, $400 per week, regardless of how many hours you worked)? YES: I was paid $ ___________________ per day week every 2 weeks month semi-monthly other (specify):__________________________________________________ I was promised $ _____________ per day week every 2 weeks month semi-monthly other (specify):__________________________________________________ NO 33b. If you were an HOURLY employee, were you paid or promised more than one hourly rate (based on the hours you worked or different job tasks)? 33a. Were you an HOURLY employee? YES: I was paid $______________ per hour. I was promised $ _____________ per hour. YES (describe): NO NO 34. Were you paid by PIECE RATE? YES NO 35. Were you paid by COMMISSION? YES NO Par t 7: W AG ES, CO M PEN SATIO N & PEN ALTIES O W ED r 36. CLAIMS CLAIM PERIOD: START DATE (Month/ Day/ Year) (Check all boxes below that apply) CLAIM PERIOD: END DATE (Month/ Day/ Year) AMOUNT EARNED / CLAIMED REGULAR WAGES (for non-overtime hours) $ OVERTIME WAGES (including double time) $ MEAL PERIOD WAGES $ REST PERIOD WAGES $ SPLIT SHIFT PREMIUM $ REPORTING TIME PAY $ COMMISSIONS *** $ VACATION WAGES *** $ BUSINESS EXPENSES $ UNLAWFUL DEDUCTIONS $ OTHER (Specify): $ ENTER SUBTOTAL (add all Amounts Earned/Claimed): $ ENTER TOTAL AMOUNT PAID: $ GRAND TOTAL OWED [Subtotal minus Total Amount Paid]: $ *** Additional DLSE form should be submitted if you are making this claim. See “Instructions for Filing a Wage Claim.” 37. Check box(es) if you are claiming: Waiting time penalties [Labor Code §203] Penalties for “bounced” checks (checks issued with insufficient funds) [Labor Code §203.1] I hereby certify that the information I have provided is true to the best of my knowledge and/or recollection. The amounts claimed are based on my best estimates at this time and may be adjusted based on further information, or based on assistance with my claim provided by DLSE. Signed: __________________________________________________ Date: ________________________________________________ Print Name: ______________________________________________ DLSE FORM 1 / WAGE ADJUDICATION (REV. 7/2012) (CONTINUED – Page 3 of 3) American LegalNet, Inc. www.FormsWorkFlow.com American LegalNet, Inc. www.FormsWorkFlow.com NOTES: Date Received Receipt Number CONFERENCE: DATES Check, Cash, etc. RECORD OF RECEIPTS Amount Phone No. of Defendant: Phone No. of Claimant: Name & Address of Advocate: Division Check Number Date Paid Balance Due Address change of Defendant as of: Address of Defendant: Address of Claimant: Phone No. of Advocate: Address change of Claimant as of: Against: Claimant: DO NOT WRITE ON THIS SIDE – For Office Use Only RECORD OF PAYMENTS TO CLAIMANT PEND: DATES Signature/Remarks Date Closed Action Number: DATE RCI COMPLAINT FILED (if applicable) DATE(S) CLAIM RECEIVED DATE BOFE COMPLAINT FILED (if applicable) Docket Date Interpreter Needed: