Memorándum standard

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TO: All Employees
FROM: Allen Payne, Risk Manager
DATE: January 20, 2011
SUBJECT: Reporting On-The-Job Injuries
As an employee of Franklin Industries, you are entitled to workers‘compensation benefits if you sustain a work-related injury or illness. Copies of the forms that need to be filed are included in this packet.
If your injury is a reportable claim, you must complete therequired forms in order to have your claim, you must complete the required forms in order to have your claim evaluated to receive benefits. If your injury requires continued treatments, prescriptionmedications, or if you were unable to work at least one full day after the day of injury, it is considered to be a reportable claim. The completed forms must be returned to the Risk Management departmentwithin 48 hours of your injury. Signing these forms is not admission of liability, but enables us to investigate and pay benefits, if applicable.
Any delay in reporting a work-related injury/illnessor in the filing of the claim forms may jeopardize your workers’ compensation benefits or delay the processing of your claim. Upon receipt of the completed claim form, you will receive anacknowledgment copy of the form and the benefits letter. If you are in need of medical attention, you must obtain authorization for treatment from your manager and receive treatment at one of the followingdesignated occupational medical facilities:
Bon Ami Medical Group, Department of Occupational & Environmental Health Services
3980 North Euclid Avenue, Suite 250, Fullerton, CA 92835-4757 (Open 24 hrs,7 days a week) 714-555-0111
St. Simon Industrial Medicine Center
5002 Orangewood Avenue, Garden Grove, CA 92841-3462 (Open 24 hrs, 7 days a week) 714-555-0190
First Response Medical Center
987Orangethorpe Avenue, Suite 110, La Palma, CA 90623-0598 (Open 24 hrs, 7 days a week) 714-555-0120
If you have an Employee’s Request for Pre-Designation of Physician form on file with the...
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