Notice Regarding Workers' Compensation Claim (5 Years)
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Notice Regarding Workers' Compensation Claim (5 Years) Form. This is a California form and can be use in General Workers Comp.
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Tags: Notice Regarding Workers' Compensation Claim (5 Years), WC-002, California Workers Comp, General
NOTICE REGARDING WORKERS' COMPENSATION CLAIM
Employee Name:
Date of Injury:
Employer Name:
Claims Administrator:
Telephone No.:
Claim Number:
YOUR CLAIM HAS BEEN INACTIVE FOR AT LEAST THE PREVIOUS 180 DAYS. YOUR
CLAIM WILL BE DISMISSED BY THE OPERATION OF LAW PURSUANT TO LABOR CODE
SECTION 5404.5, WITHOUT FURTHER NOTICE, UNLESS YOU FILE AN APPLICATION FOR
ADJUDICATION OF CLAIM WITH THE WORKERS' COMPENSATION APPEALS BOARD
WITHIN 5 YEARS OF THE DATE OF INJURY OR WITHIN ONE YEAR OF THE LAST
FURNISHING OF BENEFITS, WHICHEVER IS LATER.
Your claim(s) on the attached claim form(s) will be dismissed by operation of law if you do not file
an application for adjudication of claim with the Workers' Compensation Appeals Board within 5
years of the date of injury or within one (1) year of the last furnishing of benefits, whichever is
later. The last furnishing of benefits occurred on
and consisted of
You may contact the Division of Workers' Compensation at telephone number 1-800-736-7401 for
information about your workers' compensation claim. You may also consult an attorney.
WC-002
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