Notice to Employee (Labor Code section 2810.5) Instructions

Please enter any allowances claimed as part of minimum wage, including meal or lodging allowances.

Check this box if there is a state or federal emergency or disaster declaration applicable to the county or counties where the employee will work, issued within 30 days before their first day of employment, and that may affect their health and safety during employment.

Please provide details about any state or federal emergency or disaster declaration applicable to the employee's work location that may affect their health and safety. Fill only if 'Emergency or Disaster Declaration Applicable' is 'Yes'.

Enter the full printed name of the employee.

Enter the date on which the employee acknowledged receipt of this notice.

Please provide the full name of the employee.

Please enter the date when the employee's employment began.

Please provide the printed full name of the employer representative.

Please provide the signature of the employer representative.

Provide the full legal name of the hiring employer.

Check this box if the hiring employer is a staffing agency/business (e.g., Temporary Services Agency; Employee Leasing Company; or Professional Employer Organization [PEO]).

Check this box if the hiring employer is not a staffing agency/business (e.g., Temporary Services Agency; Employee Leasing Company; or Professional Employer Organization [PEO]).

Enter any other names under which the hiring employer is doing business, if applicable.

Enter the complete physical address of the hiring employer's main office.

Provide the mailing address of the hiring employer, if it is different from the physical address of the main office.

Enter the telephone number of the hiring employer.

Check this box if the employee accrues paid sick leave only pursuant to the minimum requirements stated in Labor Code §245 et seq., with no other employer policy providing additional or different terms for accrual and use of paid sick leave.

Check this box if the employee accrues paid sick leave pursuant to the employer's policy which satisfies or exceeds the accrual, carryover, and use requirements of Labor Code §246.

Check this box if the employer provides no less than 40 hours (or 5 days) of paid sick leave at the beginning of each 12-month period.

Check this box if the employee is exempt or partially exempt from paid sick leave by Labor Code §245.5.

Provide the state exemption and the specific subsection for the exemption if the employee is exempt or partially exempt from paid sick leave by Labor Code §245.5. Fill only if 'Employee Exempt from Sick Leave' is 'Yes'.

Provide the standard rate(s) of pay for the employee.

Provide the rate(s) of pay for overtime hours worked by the employee.

Please provide specific details for the 'Other' rate basis. Fill only if 'Rate by (check box' is 'Yes'.

Please enter the employee's regular payday schedule, such as a specific day of the week or dates within a month.

Enter the full name of the workers' compensation insurance carrier.

Enter the complete mailing address of the workers' compensation insurance carrier.

Enter the telephone number of the workers' compensation insurance carrier.

Enter the workers' compensation insurance policy number.

Enter the certificate number for consent to self-insure under Labor Code 3700. Fill only if 'Self-Insured (Labor Code 3700)' is 'Yes'.

Check this box if the employer is self-insured for workers' compensation under Labor Code 3700 and provide the Certificate Number for Consent to Self-Insure.

Check this box if a written agreement exists providing the rate(s) of pay.

Check this box if no written agreement exists providing the rate(s) of pay.

Check this box if all rate(s) of pay and their bases are contained within the written agreement. Fill only if 'Written Agreement Exists - Yes' is 'Yes'.

Check this box if not all rate(s) of pay and their bases are contained within the written agreement. Fill only if 'Written Agreement Exists - Yes' is 'Yes'.