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Printable W-4 Form for Palmdale California: What You Should Know

Workers' Compensation. Acknowledgments of Receipt of Injury Benefits Under the California Workers' Compensation Act, Pertaining to the City of Los Angeles P.O. Box 54912 Palmdale, CA 92365 Pursuant to Section 703-5 of the California State Employees' Retirement System (Casts) Act, Chapter 13A of Division 12 of the Business and Professions Code, Title 5 (the Act), as amended, the City of California hereby grants, enforces, and authorizes the following: The City of Los Angeles shall provide to the State of California the following programs: Program: Employees who are injured at the City of Los Angeles may file a claim for workers' compensation benefits under the Casts Act. The Claim to Workers' Compensation Benefits under the Casts acts shall be filed by a person at the place of work in which the worker was injured. The Claim to Workers Compensation Benefits under the Casts Act shall be filed before the date of expiration of any worker's compensation benefit under the Casts Act. The Claim shall be accompanied by an Application for Workers' Compensation Benefits under the Casts Act. The Application for Workers' Compensation Benefits under the Casts Act shall be filed by a worker who has worked as an employee within the City of Los Angeles for at least 12 consecutive months, with proof of his or her work records, the identification number of the City of Los Angeles, the name of the worker and the date he or she started work where the worker was injured, and with all other information as required by law to verify identification, eligibility and length of employment of the worker. To file a claim, contact the Department of Personnel, Bureau of Health and Human Services, Department of Health Care Administration at or contact the Department of Benefits and Services, Bureau of Benefits and Services, Department of Administrative Services, Division of Benefits at or by e-mail at. The claim forms shall be available from any Department of Personnel, Bureau of Health and Human Services or Department of Benefits and Services, Division of Benefits at or by e-mail at benefitslbds.ca.gov.

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