Page 565 - Safety Memo

DECLINATION OF WORKERS’ COMPENSATION BENEFITS
(MEDICAL TREATMENT)

I, _____________________________________ understand that I am entitled to workers’
(employee)

compensation benefits, examination and/or treatment under my employer’s workers’
compensation insurance.

I reported a work related incident/injury on _________________. As a result of the
(date)

incident, I injured my _________________________________________________
(body part)

while performing _________________________________________________ job task.

I understand this declination is a voluntary decision and does not waive my rights to
future benefits under the State of California Workers Compensation laws.

I agree to notify my manager immediately if, in the future, I feel medical treatment for
this injury becomes necessary, at which point my manager will refer me to the medical
clinic.

I was also provided a DWC-1 claim form.

______________________________________________
Employee Signature

_______________________________________________
Manager

_____________________________
Date

18