Time Hire Pamphlet Form PDF Details

Finding the right candidate for a job can be an arduous process. From writing and posting the job listing to understanding your recruiting processes, there are multiple challenges businesses need to consider when hiring new talent. One of these considerations is correctly setting up a time hire pamphlet form that applicants can fill out in order to apply for a position. By streamlining this important aspect of hiring, you’ll ensure that you’re legally managing potential employees while also ensuring they have easy access to applying for their ideal role. In this blog post, we will discuss how creating a properly formatted time hire pamphlet form can help simplify the recruitment process and give organizations peace of mind knowing they are making considered decisions when it comes to their team growth plans.

Form NameTime Hire Pamphlet Form
Form Length8 pages
Fillable fields0
Avg. time to fill out2 min
Other namestime of hire pamphlet california 2021, time of hire pamphlet california, california workers compensation pamphlet pdf, time hire pamphlet

Form Preview Example


This pamphlet, or a similar one that has been approved by the Administrative Director, must be given to all newly hired employees in the State of California. Employers and claims administrators may use the content of this document and put their logos and additional information on it. The content of this pamphlet applies to all industrial injuries that occur on or after January 1, 2013.


If you get hurt on the job, your employer is required by law to pay for workers’ compensation benefits. You could get hurt by:

One event at work. Examples: hurting your back in a fall, getting burned by a chemical that splashes on your skin, getting hurt in a car accident while making deliveries.


Repeated exposures at work. Examples: hurting your wrist from using vibrating tools, losing your hearing because of constant loud noise.


Workplace crime. Examples: you get hurt in a store robbery, physically attacked by an unhappy customer.

Discrimination is illegal

It is illegal under Labor Code section 132a for your employer to punish or fire you because you:

File a workers’ compensation claim

Intend to file a workers’ compensation claim

Settle a workers’ compensation claim

Testify or intend to testify for another injured worker.

If it is found that your employer discriminated against you, he or she may be ordered to return you to your job. Your employer may also be made to pay for lost wages, increased workers’ compensation benefits, and costs and expenses set by state law.


Medical care: Paid for by your employer to help you recover from an injury or illness caused by work. Doctor visits, hospital services, physical therapy, lab tests and x-rays are some of the medical services that may be provided. These services should be necessary to treat your injury. There are limits on some services such as physical and occupational therapy and chiropractic care.

Temporary disability benefits: Payments if you lose wages because your injury prevents you from doing your usual job while recovering. The amount you may get is up to two-thirds of your wages. There are minimum and maximum payment limits set by state law. You will be paid every two weeks if you are eligible. For most injuries, payments may not exceed 104 weeks within five years from your date of injury. Temporary disability (TD) stops when you return to work, or when the doctor releases you for work, or says your injury has improved as much as it’s going to.

Permanent disability benefits: Payments if you don’t recover completely. You will be paid every two weeks if you are eligible. There are minimum and maximum weekly payment rates established by state law. The amount of payment is based on:

OYour doctor’s medical reports

OYour age

OYour occupation

Supplemental job displacement benefits: This is a voucher for up to $6,000 that you can use for retraining or skill enhancement at an approved school, books, tools, licenses or certification fees, or other resources to help you find a new job. You are eligible for this voucher if:

OYou have a permanent disability.

OYour employer does not offer regular, modified, or alternative work, within 60 days after the claims administrator receives a doctor’s report saying you have made a maximum medical recovery.

Death benefits: Payments to your spouse, children or other dependents if you die from a job injury or illness. The amount of payment is based on the number of dependents. The benefit is paid every two weeks at a rate of at least $224 per week. In addition, workers’ compensation provides a burial allowance.


You may file a claim with the Employment Development Department (EDD) to get state disability benefits when workers’ compensation benefits are delayed, denied, or have ended. There are time restrictions so for more information contact the local office of EDD or go to their web site www.edd.ca.gov.

If your injury results in a permanent disability (PD) and the state determines that your PD benefit is disproportionately low compared to your earning loss, you may qualify for additional money from the Department of Industrial Relation’s special earnings loss supplement program also known as the return to work program. If you have questions or think you qualify, contact the Information & Assistance Unit by going to www.dwc.ca.gov and looking under “Workers’

Compensation programs and units” for the “Information & Assistance Unit” link or visit the DIR web site at www.dir.ca.gov.

Workers’ compensation fraud is a crime

Any person who makes or causes to be made any knowingly false statement in order to obtain or deny workers’ compensation benefits or payments is guilty of a felony. If convicted, the person will have to pay fines up to $150,000 and/or serve up to five years in jail.


Report your injury to your employer

Tell your supervisor right away no matter how slight the injury may be. Don’t delay – there are time limits. You could lose your right to benefits if your employer does not learn of your injury within 30 days. If your injury or illness is one that develops over time, report it as soon as you learn it was caused by your job.

If you cannot report to the employer or don’t hear from the claims administrator after you have reported your injury, contact the claims administrator yourself.

Workers’ compensation insurance company or if employer is self- insured, person responsible for handling the claim is:


Address: ___________________________________________________

Phone: ____________________________________________________.

You may be able to find the name of your employer’s workers’ compensation insurer at www.caworkcompcoverage.com. If no coverage exists or coverage has expired, contact the Division of Labor Standards Enforcement at www.dir.ca.gov/DLSE as all employees must be covered by law.

Get emergency treatment if needed

If it’s a medical emergency, go to an emergency room right away. Tell the medical provider who treats you that your injury is job related. Your employer may tell you where to go for follow up treatment.

Emergency telephone number: Call 911 for an ambulance, fire department or police. For non-emergency medical care, contact your employer, the workers’ compensation claims administrator or go to this facility:


Fill out DWC 1 claim form and give it to your employer

Your employer must give you a DWC 1 claim form within one working day after learning about your injury or illness. Complete the employee portion, sign and give it back to your employer. Your employer will then file your claim with the claims administrator. Your employer must authorize treatment within one working day of receiving the DWC 1 claim form.

If the injury is from repeated exposures, you have one year from when you realized your injury was job related to file a claim.

In either case, you may receive up to $10,000 in employer-paid medical care until your claim is either accepted or denied. The claims administrator has up to 90 days to decide whether to accept or deny your claim. Otherwise your case is presumed payable.

Your employer or the claims administrator will send you “benefit notices” that will advise you of the status of your claim.


What is a Primary Treating Physician (PTP)?

This is the doctor with overall responsibility for treating your injury or illness. He or she may be:

The doctor you name in writing BEFORE you get hurt on the job

A doctor from the medical provider network (MPN)

The doctor chosen by your employer during the first 30 days of injury if your employer does not have an MPN or

The doctor you chose after the first 30 days if your employer does not have an MPN.

What is a Medical Provider Network (MPN)?

An MPN is a select group of health care providers who treat injured workers. Check with your employer to see if they are using an MPN.

If you have not named a doctor before you get hurt and your employer is using an MPN, you will see an MPN doctor. After your first visit, you are free to choose another doctor from the MPN list.

What is Predesignation?

Predesignation is when you name your regular doctor to treat you if you get hurt on the job. The doctor must be a medical doctor (M.D.), doctor of osteopathic medicine (D.O.) or a medical group with an M.D. or D.O. You must name your doctor in writing BEFORE you get hurt or become ill.

You may predesignate a doctor if you have health care coverage for non-work injuries and illnesses. The doctor must have:

Treated you

Maintained your medical history and records before your injury and

Agreed to treat you for a work-related injury or illness before you get hurt or become ill.

You may use the “predesignation of personal physician” form included with this pamphlet. After you fill in the form, be sure to give it to your employer.

If your employer does not have an approved MPN, you may name your chiropractor or acupuncturist to treat you for work related injuries. The notice of personal chiropractor or acupuncturist must be in writing BEFORE you get hurt. You may use the form included in this pamphlet. After you fill in the form, be sure to give it to your employer. State law does not allow a chiropractor to continue as your treating physician after 24 visits.


If you have a concern, speak up. Talk to your employer or the claims administrator handling your claim and try to solve the problem. If this doesn’t work, get help by trying the following:

Contact the Division of Workers’ Compensation (DWC) Information and Assistance (I&A) Unit

All 24 DWC offices throughout the state provide information and assistance on rights, benefits and obligations under California's workers' compensation laws. I&A officers help resolve disputes without formal proceedings. Their goal is to get you full and timely benefits. Their services are free.

To contact the nearest I&A Unit, go to www.dwc.ca.gov and under “Workers’ Compensation programs and units”, click on “Information & Assistance Unit.” At this site you will find fact sheets, guides and information to help you.

The nearest I&A Unit is located at:


Phone number: ________________________________________________.

Consult with an attorney

Most attorneys offer one free consultation. If you decide to hire an attorney, his or her fees may be taken out of some of your benefits. For names of workers’ compensation attorneys, call the State Bar of California at (415) 538-2120 or go to their website at www.californiaspecialist.org. You may get a list of attorneys from your local I&A Unit or look in the yellow pages.


Your employer may not pay workers’ compensation benefits if you get hurt in a voluntary off- duty recreational, social or athletic activity that is not part of your work-related duties.

Additional rights

You may also have other rights under the Americans with Disabilities Act (ADA) or the Fair Employment and Housing Act (FEHA). For additional information, contact FEHA at (800) 884- 1684 or the Equal Employment Opportunity Commission (EEOC) at (800) 669-4000.

The information contained in this pamphlet conforms to the informational requirements found in Labor Code sections 3551 and 3553 and California Code of Regulation, Title 8, sections 9880 and 9883. This document is approved by the Division of Workers’ Compensation administrative director.

Revised 12/20/12 and effective for dates of injuries on or after 1/1/13


In the event you sustain an injury or illness related to your employment, you may be treated for such injury or illness by your personal medical doctor (M.D.), doctor of osteopathic medicine (D.O.) or medical group if:

you have group health coverage;

the doctor is your regular physician, who shall be either a physician who has limited his or her practice of medicine to general practice or who is a board-certified or board-eligible internist, pediatrician, obstetrician-gynecologist, or family practitioner, and has previously directed your medical treatment, and retains your medical records;

your "personal physician" may be a medical group if it is a single corporation or partnership composed of licensed doctors of medicine or osteopathy, which operates an integrated multispecialty medical group providing comprehensive medical services predominantly for non-occupational illnesses and injuries;

prior to the injury your doctor agrees to treat you for work injuries or illnesses;

prior to the injury you provided your employer the following in writing: (1) notice that you want your personal doctor to treat you for a work-related injury or illness, and (2) your personal doctor’s name and business address.

You may use this form to notify your employer if you wish to have your personal medical doctor or a doctor of osteopathic medicine treat you for a work- related injury or illness and the above requirements are met.


To: ____________________________ (name of employer) If I have a work-related injury or illness, I

choose to be treated by:


(name of doctor)(M.D., D.O., or medical group)

____________________________________________________________(street address, city, state, ZIP)

___________________________________________(telephone number)

Employee Name (please print):

Employee’s Address:




Physician: I agree to this Predesignation:


(Physician or Designated Employee of the Physician or Medical Group)

The physician is not required to sign this form, however, if the physician or designated employee of the physician or medical group does not sign, other documentation of the physician’s agreement to be predesignated will be required pursuant to Title 8, California Code of Regulations, section 9780.1(a)(3).


If your employer or your employer’s insurer does not have a Medical Provider Network, you may be able to change your treating physician to your personal chiropractor or acupuncturist following a work-related injury or illness. In order to be eligible to make this change, you must give your employer the name and business address of a personal chiropractor or acupuncturist in writing prior to the injury or illness. Your claims administrator generally has the right to select your treating physician within the first 30 days after your employer knows of your injury or illness. After your claims administrator has initiated your treatment with another doctor during this period, you may then, upon request, have your treatment transferred to your personal chiropractor or acupuncturist.

You may use this form to notify your employer of your personal chiropractor or acupuncturist.

State law does not allow a chiropractor to continue as your treating physician after 24 visits.

Your Chiropractor or Acupuncturist’s Information:


(name of chiropractor or acupuncturist)


(street address, city, state, zip code)


(telephone number)

Employee Name (please print):


Employee’s address:




How to Edit Time Hire Pamphlet Form Online for Free

hire pamphlet latest can be filled in without difficulty. Just make use of FormsPal PDF editing tool to complete the job without delay. The editor is continually updated by our staff, receiving new awesome functions and becoming even more convenient. To get the process started, consider these simple steps:

Step 1: Firstly, open the tool by pressing the "Get Form Button" at the top of this page.

Step 2: The editor enables you to change most PDF documents in a variety of ways. Improve it by including personalized text, adjust existing content, and place in a signature - all at your fingertips!

When it comes to fields of this precise document, this is what you need to know:

1. Firstly, when completing the hire pamphlet latest, start with the part that contains the subsequent blanks:

Filling out part 1 of california time of hire pamphlet 2021

2. Just after filling out the last section, go to the next step and enter all required particulars in all these blanks - Compensation programs and units, Workers compensation fraud is a, Any person who makes or causes to, WHAT SHOULD I DO IF I HAVE AN, Report your injury to your, and Workers compensation insurance.

Workers compensation insurance, Compensation programs and units, and Workers compensation fraud is a inside california time of hire pamphlet 2021

3. This part is generally straightforward - fill in all of the blanks in Workers compensation insurance, and You may be able to find the name in order to complete this part.

Filling in segment 3 in california time of hire pamphlet 2021

4. It is time to complete this next part! Here you've got all these Emergency telephone number Call, Fill out DWC claim form and give, Your employer or the claims, and MORE ABOUT MEDICAL CARE empty form fields to do.

Stage no. 4 for filling out california time of hire pamphlet 2021

Always be very careful when filling out Fill out DWC claim form and give and Your employer or the claims, as this is where a lot of people make errors.

5. As you draw near to the last sections of the document, there are a few extra requirements that should be met. Particularly, Contact the Division of Workers, To contact the nearest IA Unit go, The nearest IA Unit is located at, Address, and Phone number must all be filled out.

Stage no. 5 in filling out california time of hire pamphlet 2021

Step 3: Right after you have looked over the information in the file's blanks, click "Done" to conclude your form at FormsPal. Try a 7-day free trial account with us and obtain instant access to hire pamphlet latest - downloadable, emailable, and editable from your FormsPal account page. FormsPal guarantees risk-free document tools devoid of data recording or any type of sharing. Feel safe knowing that your data is secure here!