TO:                AIR RESOURCES BOARD EMPLOYEE

SUBJECT:     ACKNOWLEDGMENT OF RECEIPT OF SCIF 3301, EMPLOYEE'S
                     CLAIM FOR WORKERS' COMPENSATION BENEFITS

Attached is the SCIF 3301. Your supervisor is required to provide this form to you upon receiving notification of a work-related injury/illness which required professional medical treatment or where you lost time from work beyond the date of injury/illness. If in the future you do see a doctor or lose time from work due to this work-related injury/illness, complete the SCIF 3301 and return it to your supervisor.

PLEASE NOTE: Completion of the SCIF 3301 is necessary only if you wish to pursue this claim as a work-related injury/illness.  Complete the top portion of the form and return it to your supervisor.

ARB's insurance carrier is the State Compensation Insurance Fund (SCIF). Upon receipt of the SCIF 3301, SCIF will have up to 90 calendar days to make a decision to either accept or deny your claim.

Note to Supervisor: Enter the date SCIF 3301 was given or mailed to the employee. Detach the bottom portion of this form and route to the Workers' Compensation Analyst along with the completed SCIF 3067, Employer's Report of Occupational Injury or Illness.

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EMPLOYEE'S ACKNOWLEDGMENT OF RECEIPT OF SCIF 3301

This is to acknowledge that I have received a SCIF Form 3301, Employee's Claim for Workers' Compensation Benefits.

I understand that if I wish to pursue this claim as a work-related injury/illness, it is my responsibility to complete the SCIF 3301 and return it to my supervisor.

Employee's Name

Employee's Division

 

Date of Injury Illness / Date SCIF Received

Employee's Signature

SUPERVISOR'S SECTION

Date SCIF 3301 Given/Mailed to Employee

Supervisor's Signature