Report Injuries

If you are injured at work, you must take the following steps immediately in order to qualify for Workers’ Compensation benefits:

  1. Report the injury to your supervisor or Josh Etherington408-924-2155
    1. If you must seek medical attention first, notify your supervisor or Josh Etherington @ 408-924-2155 as soon as possible.
  2. Seek medical attention

Your supervisor must then take the following steps:

  1. Complete the Employer’s Report of Occupational Injury or Illness [pdf] 
  2. Write the description of the accident using the employee’s own account
  3. Give you (the employee) a copy of the Workers’ Compensation Claim Form (DWC 1) and Notice of Potential Eligibility [pdf]
  4. Sign and submit both forms via DocuSign to Josh Etherington when complete.

Additional Information


For additional information contact Josh Etherington.