DISTRICT OF COLUMBIA GOVERNMENT DEPARTMENT OF EMPLOYMENT SERVICESOFFICE OF WORKERS' COMPENSATIONPO BOX 56098 WASHINGTON, DC 20011 (202) 671-1000 (202) 671-1929 (fax)Warning: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalities include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant.NOTICE OF COMPLIANCECOURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .TO EMPLOYEES:::::::Index No.1. You are required by law to report promptly to your employer and the Office of Workers' Compensation an occupational injury or disease, even if you deem it to be minor. Form No. 7 DCWC, Notice of Accidental Injury or Occupational Disease, to be obtained from the employer or the Office of Workers'Compensation, must be used for that purpose. After you have completed and signed it, you should mail it to the Office of Workers' Compensation at the above address, and to your employer.Calendar No.JUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)2. You are entitled, if required, to the services of a physician or hospital of your choice and lost wages. Call (202) 671-1000 for information.3. You may not sue your employer as a result of a work-connected injury or disease by reason of your exclusive remedy under the Workers'Compensation Law.4. In order to preserve your right to benefits under the DC Workers'Compensation Law, you must file a written claim on Form No. 7A DCWC, Employee's Claim Application, within one (1) year after your injury, or within (1) year after the last payment of benefits.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5. If you desire information regarding your rights and obligations prescribed by law, you may call your employer first. If you need further information you may call the Office of Workers'Compensation at (202) 671-1000.PEOPLE OF THE STATE OF NEW YORK6. The law gives you the right to be represented if you so desire.TO EMPLOYERS1. You are required to have Workers'Compensation insurance coverage if you have 1 or more employees.GREETINGS:2. You are required to display this poster at each worksite so that it will be of the greatest possible benefit to your employees.WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the Honorable,3. You must file an Employer's First Report of Injury or Occupational Disease, Form No. 8 DCWC, with the Office of Workers' Compensation, copy to the nearest claim office of your insurer, on all occupational injuries or disease, as soon as possible, but no later than 10 days after the date of knowledge thereof.located at ofo'clock in the day ofnoon, and at any recessed , on the, 20, at adjourned date, to testify and give evidence as a witness in this action on the part of the4. Your employee must file Form No. 7 DCWC, Employee's Notice of Accidental Injury or Occupational Disease. Please provide your employee with Form No. 7 DCWC and direct them to complete it and return it to you and the Office of Workers' Compensation. Once you have received notice from the employee, you are required to send the employee a notice of his/her rights and obligations by certified mail, return receipt requested.Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a your failure to comply.5. You are required to report to the Office of Workers'Compensation, and your insurer, and disability of more than 3 days which was not previously reported, as soon as possible, but no later than 10 days after the date of knowledge thereof.Witness, Honorable, one of the Justices of the6. You are required to furnish, or cause to be furnished, reasonable medical and hospital services, other remedial care or vocational rehabilitation, and various types of disability compensation, to an injured or disabled employee.day of, 20 County,7. You are required to obtain from the insurer identified below a supply of all required Workers' Compensation Forms, or you may download the forms and notice mentioned above at our website http://does.dc.gov(Attorney must sign above and type name below)NOTICE: Violation of the various provisions of the Workers' Compensation law provides for civil penalties.The undersigned employer hereby gives notice of compliance with all provisions of the Workers'Compensation Law andAdministrative RegulationsAttorney(s) forNAME OF INSURANCE COMPANYNAME OF EMPLOYERBY Office and P.O. AddressEmployer ID NumberTelephone No.: Facsimile No.: E-Mail Address:(if number unknown, employer to request from IRS)Mobile Tel. No.:THIS NOTICE IS TO BE POSTED CONSPICUOUSLY IN AND ABOUT EMPLOYER'S PLACE(S) OF BUSINESS FORM NO. 1 DCWCRevised June, 2002American LegalNet, Inc. www.USCourtForms.com
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