New Employee Paperwork Summary

Transcription

New Employee Paperwork Summary
EMPLOYEE NAME __________________________________ WWID _____________________
Completed by New Hire
1.
Appendix A / Employment Agreement
2.
Information Supplement 1
3.
Information Supplement 2
4.
Code of Conduct Questionnaire
5.
Intel Employee Agreement
6.
New Employee Orientation Certification
7.
Intel Retirement Plans Prior Service Questionnaire
8.
New Hire Benefits Form
9.
Medical Provider Network (MPN) Handbook
10.
Data Protection Authorization for New Hires
Updated Forms ©Intel Corporation REV JUNE 2014
APPENDIX A
TO EMPLOYMENT AGREEMENT SECTION 5
Employee Name: ______________________________ WWID: ______________________
Do you own or control, in whole or in part, any Preexisting Employee Intellectual Property
(including patents and patent applications) that you are not licensing to the Intel Group, as
defined in Section 5 as Identified Employee Controlled Intellectual Property? (Do not
answer “Yes” for patents which your former employer or other party owns, but which merely
name you as an inventor.)
If yes, list such Identified Employee Controlled Intellectual Property (attach or specifically
identify relevant patents, patent applications, or similar disclosures):
Do you have an economic interest in any patents, pending applications or other Preexisting
Employee Intellectual Property that you do not own or control, for example patents or
applications owned by a University on which you are named an inventor?
If yes, list such Preexisting Employee Intellectual Property (attach or specifically identify
relevant patents, patent applications, or similar disclosures):
Attach additional sheets as necessary. Number of additional sheets attached: ____
Employee Signature: ___________________________ Date: _________________
Information Supplement
PLEASE PRINT
Complete all requested information. All information you provide will be handled in strict confidence.
EMPLOYEE NAME: ___________________________________________________________________________
LAST
FIRST
MIDDLE
WORLDWIDE ID: ____________________SOCIAL SECURITY NUMBER: _____-____-______
HOME PHONE NUMBER: _______________________________________________________
EMERGENCY CONTACT: _______________________________________________________
NAME
RELATIONSHIP
PHONE NUMBER
Technology Transfer Control Information
Intel works in technology areas that are subject to export controls by the United States government. Intel
must obtain authorization from the Bureau of Industry and Security, U.S. Department of Commerce, before
employing citizens from certain countries. This questionnaire is designed to assist Intel in determining
whether it must apply for an export license on behalf of a potential new hire.
QUESTION 1
As of today’s date, are you one of the following:

Citizen or Legal National of the United States;
Lawful Permanent Resident (PR) of the United States (Note: Only having an application for PR

status pending requires a “NO” answer.)

A person granted refugee status in the United States (Note: Only having public interest parole,
humanitarian parole, or temporary protected status requires a “NO” answer.)

A person granted asylum status in the United States (Note: Only having an asylum application
pending requires a “NO” answer)
□
YES □ NO
NOTE: Individuals in nonimmigrant visa status such as B, L, H visa status should answer NO.
QUESTION 2
If your answer to Question 1 is “NO”, but you claim that you have authorization to work in the United States
on a full-time basis, please identify the basis for your right to work in U.S:
□E
□F-1
□H-1B
□H-3
□J-1
□L-1
□TN
□EAD
□O-1
Visa/work authorization: start date___________ expiration date________
Check, if applicable: □ Optional Practical Training
□ Curricular Practical Training
(If you checked either box, bring a copy of the I-20 form to NEO)
QUESTION 3
If your answer to Question 1 is “NO” to all the legal status categories, please answer the following:

What is your citizenship? ___________________________________________________

If you have multiple citizenship (i.e., citizenship in two or more countries), name the country in
which you have the most recent citizenship and provide the citizenship issuance date.
________________________________________________________________________
If you have Permanent Residency (PR) in multiple countries (i.e., PR in two or more countries),

name the country in which you have the most recent PR and provide the PR issuance date.
________________________________________________________________________
I understand that any work assignment at Intel may be conditioned upon export license requirements
I CERTIFY THAT THE INFORMATION SUPPLIED IS TRUE AND CORRECT
___________________________________________________
EMPLOYEE SIGNATURE
Rev. 11/2010
_________________________________
DATE
Information Supplement, page 2
The following information is required for confirmation of employment and/or benefit status:
EMPLOYEE NAME ________________________________
DATE OF BIRTH ___/____/____
MARITAL STATUS: □ SINGLE □ MARRIED
GENDER: □ MALE □ FEMALE
__________________________________________________________
Intel’s Commitment to Diversity
Our diversity is our strength. We want to be a workplace of choice for all people and we value the unique
perspectives offered by a diverse workforce. Intel does not discriminate on the basis of race, color, religion,
sex, national origin, ancestry, age, disability, veteran status, marital status, gender identity, gender
expression, or sexual orientation. This principal applies to all areas of employment: recruitment and hiring,
training, performance evaluations, promotions and transfers, compensation and benefits, and social and
recreational programs.
We encourage and invite you to complete the information below. Your information is critical to our efforts in
complying with federal and state Equal Employment Opportunity record keeping, reporting, and other legal
requirements. While identifying is voluntary, Intel will also use this information to invite you to applicable Intel
events and related communications. Any information you provide will be kept confidential and will be used
only in accordance with legal requirements
What is your race? Please select all that apply. You may also select one race or ethnicity category that you
most closely identify with as primary:
□
□
□
□
□
□
Hispanic, Latino, or of Spanish Origin - A person having origins in any of the
original peoples of Cuba, Mexico, Puerto Rico, South or Central America, or other
Spanish culture or origin regardless of race.
American Indian or Alaska Native - A person having origins in any of the
original peoples of North and South America (including Central America), and
who maintain tribal affiliation or community attachment.
Asian - A person having origins in any of the original peoples of the Far East,
Southeast Asia, or the Indian Subcontinent, including, for example, Cambodia,
China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand,
and Vietnam.
Black or African American - A person having origins in any of the black racial
groups of Africa.
Native Hawaiian or Other Pacific Islander - A person having origins in any of
the peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
White - A person having origins in any of the original peoples of Europe, the
Middle East, or North Africa.
HAVE YOU EVER SERVED IN THE U.S. MILITARY (ACTIVE, RESERVE, AND/OR NATIONAL GUARD?)
If YES the below is all about you.
Intel welcomes military veterans, active duty, and guard and reserves! We value your experience and know that the military
shares our values: discipline, quality, risk taking, results orientation, customer orientation, and great place to work. More
than simply words, they are something we live by each day. They speak to everyone within our diverse workforce, and
service members who have lived and breathed these values will do well at Intel. If you have served in the military, we invite
you to identify yourself below as a proud member of this community. Identifying your military status is voluntary but it
provides Intel with critical, relevant, and accurate data on our workforce which translates into enhanced results in
recruiting, retaining, promoting, and supporting our military employees. As a part of Intel’s military community, you can
choose to be involved in additional events, help build programs, and foster ongoing efforts.
Please check which category you fall into:
□
□
ACTIVE DUTY WARTIME OR CAMPAIGN BADGE VETERAN: You served on active duty in the U.S.
military, ground, naval or air service during a war or in a campaign or expedition for which a campaign
badge has been authorized.
NATIONAL GUARD OR RESERVE SERVICE: You are serving or served in the National Guard or Reserve
but were not called or drafted into active service by the U.S.
In addition, please check all that are applicable (you may check more than one category):
□
DISABLED MILITARY/VETERAN: You (a) were discharged or released from active duty because of
a service-connected disability, or (b) are entitled to compensation under laws administered by
the Secretary of Veterans Affairs.
□
RECENTLY SEPARATED MILITARY/VETERAN: You served on active duty within the last 3 years.
DATE OF MOST RECENT DISCHARGE: ___/____/____
□
ARMED FORCES SERVICE MEDAL MILITARY/VETERAN: While serving on active duty, you
participated in a military operation for which an Armed Forces service medal was awarded.
Code of Conduct Questionnaire
Intel Confidential
If you answer “Yes”, to Questions 1-2 below, you must review the Guidelines regarding Personal Appointment of Intel
Employees to Boards of Outside Organizations, and if required, complete an “Outside Directorship Conflict of Interest
Questionnaire” and follow the approval process outlined in the guidelines and Questionnaire. If you answer “Yes”, to
Questions 3-4 below, you must disclose to your manager, in writing, the existence and nature of your outside relationship
or employment and include your disclosure in this form (see below).* These disclosures must be made within the first
three weeks of employment, so that Intel can determine if it creates an actual or perceived conflict of interest with Intel’s
business interests.
1. Are you a member of a board of directors, board of advisers, government advisory commission or similar governing
or advisory body of a non-Intel company, academic institution, industry group, government entity or non-profit
organization? If the answer is “No”, please go to question 3.
No
Yes
If you answered “Yes”, please provide the name of the company/organization on whose board or governing/advisory body
you serve:
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
2. If you answered “Yes” to question 1,
• Is this company/organization contemplating doing business with Intel as a vendor, purchaser, contractor or otherwise?
or
• Have you participated in or attempted to influence any Intel decision involving this company/organization?
No
Yes
3. Are you currently employed or do you have any financial or business interest that could present a conflict (or even
the appearance of a conflict) with Intel’s interest, such as consulting, operating a personal business, holding political
office, etcetera, outside of Intel?
No
Yes
If you answered “Yes”, please provide the name of the employer and describe the nature of the financial or business
Interest:
______________________________________________________________________________________________________
______________________________________________________________________________________________________
4. If you answered “Yes” to question 3,
• Does this outside employment or financial or business interest relate to or resemble business conducted at Intel?
or
• Could your outside employment or financial or business activity interfere – or even appear to interfere – with your
ability to make sound business decisions in the best interest of Intel?
No
Yes
*
Disclosure:
1. What external entity does this involve (name of customer, vendor, subcontractor, contingent worker, etc.)?
2.
What is the entity’s business relationship with Intel (customer, vendor, partner, etc.)?
3.
What is your association to the entity (investor, friend, family, ownership, etc.)?
4.
How long have you had the association to the entity?
5.
If you know someone at the entity, how long have they been at the entity and what is their role?
6.
How is your contact at the entity associated with Intel business?
7.
What is your role at Intel and could that role have any direct or indirect influence on Intel business with the external entity (i.e are
you involved in procurement, influence, or direct decisions related to this entity)?
8.
What, if any, information do you use at Intel which may relate to the Intel association with the external entity. (i.e. project/product
information, procurement process, etc.)
____________________________________
____________________________________
_____________
____________________________________
PRINTED NAME
EMPLOYEE SIGNATURE
DATE
WORLDWIDE ID
Updated Intel Rev 12/2013
Distribution: White Copy – US Records CH3-171 Yellow Copy – Employee Pink Copy –US Records CH3-171
EMPLOYMENT AGREEMENT
In exchange for being employed by Intel Corporation or any of its subsidiaries, affiliates or
successors (collectively called “Intel”) in this Agreement, I agree to the following:
1. General Conduct.
I will perform my assigned Intel duties and comply with all Intel policies, procedures, guidelines, rules, and
instructions, including Intel’s Code of Conduct, Employment Guidelines and Corporate Information Security and
Security policies.
2. Prior Third Party Information.
I will not bring to Intel, disclose to anyone at Intel, or use as part of my Intel work any proprietary or confidential
information of any former employer or third party without their written authorization.
3. Confidential Information and Intel Property.
During and after my Intel employment, I will hold in strict confidence and not disclose or use any Confidential
Information connected with Intel business or the business of any of Intel’s suppliers, customers, employees, or
contractors unless (i) such disclosure or use is required in connection with my Intel work, (ii) such information
becomes lawfully and publicly known outside Intel, or (iii) an Intel officer expressly authorizes such disclosure or use
in advance and in writing. For purposes of this Agreement, Confidential Information includes, without limitation:
technical information (e.g. roadmaps, schematics, source code, specifications), business information (e.g. product
information, marketing strategies, markets, sales, customers, customer lists or phone books), personnel information
(e.g. organizational charts, employee lists, skill sets, employee health information, names, phone numbers, email
addresses, personnel files, employee compensation except where the disclosure of such personnel information is
permissible under local labor law such as the right of employees to discuss compensation and working conditions
under the US National Labor Relations Act), and other non-public Intel data and information of a similar nature. I
understand and agree that all Confidential Information that I acquire in connection with my Intel employment is Intel’s
exclusive property. I agree to return to Intel all of its Confidential Information (hard or soft copies; originals and
copies) as well as all devices and equipment belonging to Intel (including computers, handheld electronic devices,
telephone equipment and other electronic devices) either at the termination of my Intel employment or upon Intel’s
request. I agree that any violation of this provision will result in immediate and irreparable injuries and harm to Intel,
and that Intel shall have the option of pursuing all available legal and equitable remedies, including injunctive relief
and specific performance.
4. Ownership of Proprietary Developments.
Except as provided in the next sentence, I agree that all trade secrets, copyrights, mask works, trademarks,
inventions (including service inventions), discoveries, designs, formulae, processes, methods, manufacturing
techniques, improvements, ideas, copyrightable works, and other intellectual property which I create, invent or
discover alone or with others during my Intel employment, (collectively “Proprietary Developments”) are Intel’s sole
property from the moment of their creation, invention or discovery. This shall not apply to an invention that I develop
entirely on my own time without using Intel equipment, supplies, facilities, or trade secret information, except for
those inventions that either: (1) relate at the time of conception or reduction to practice of the invention to Intel
business, or actual or demonstrably anticipated research or development of Intel; or (2) result from any work
performed by me for Intel. I agree that Intel has and shall always have sole legal and equitable title to all Proprietary
Developments and I have no right to compensation for such Proprietary Developments. I agree to promptly disclose
Proprietary Developments to Intel, and to the full extent allowed by law, but only to the extent not already owned by
Intel pursuant to this Agreement and applicable law, hereby assign to Intel all rights in the Proprietary Developments.
I agree that during and after my employment with Intel I will provide all assistance that Intel reasonably requests to
secure or enforce its rights throughout the world with respect to Proprietary Developments, including signing all
necessary documents to secure or memorialize those rights. If I fail or refuse to sign documents necessary to secure
or enforce Intel’s rights, or if Intel cannot locate me through the exercise of reasonable diligence, I irrevocably
appoint Intel or its designee as my attorney to sign such documents in my name. I waive any rights that I may have in
any Proprietary Developments and, to the extent that such waiver is ineffective under applicable law until a
Proprietary Development is created, invented or discovered, I agree to waive such rights immediately upon the
creation, invention or discovery of such Proprietary Development.
5. Licensed and Non-Licensed Preexisting Employee Intellectual Property.
As used in this Agreement “Preexisting Employee Intellectual Property” means intellectual property that I
created prior to my employment with Intel.
I have specifically listed in Appendix A all Preexisting Employee Intellectual Property that I, in whole or in part,
own or control, or have the right to license and intend to exclude from licensing to Intel (“Identified Employee
Controlled Intellectual Property”).
I agree that I will not use or disclose during my employment any Identified Employee Controlled Intellectual
Property without the prior written consent of Intel. If I disclose or use any Identified Employee Controlled
Intellectual Property without the prior written consent of Intel, I automatically and immediately grant Intel a
non-exclusive, non-transferable (except within Intel), perpetual, irrevocable, royalty-free, world-wide license to all of
the Identified Employee Controlled Intellectual Property disclosed or used with the right to sublicense, to make,
have made, use, sell, offer to sell, import, reproduce, have reproduced, prepare derivative works of, distribute, and
otherwise dispose of, any product or document, under all patents, trade secrets, copyrights and copyrightable
works, mask works, trademarks, inventions, discoveries, designs, formulae, processes, methods, manufacturing
techniques, improvements, and ideas.
I have also listed in Appendix A all Preexisting Employee Intellectual Property in which I have an economic interest
(but do not own or control) and for which I do not have the right to grant a license to Intel.
For the avoidance of doubt, I agree that any Preexisting Employee Intellectual Property that I, in whole or in part,
own, control or have the right to license and that is neither Identified Employee Controlled Intellectual Property nor
identified in Appendix A prior to my employment in sufficient detail to Intel to identify its subject matter is licensed to
Intel in the same manner and scope as disclosed or used Identified Employee Intellectual Property.
I agree that if I fail to make any required disclosure or breach any term of Sections 4 and 5, any applicable
limitations periods shall be tolled and shall not run as to any claim, right, or cause of action Intel may have relating
to such disclosure or breach that would have been discovered had the required disclosure been made, until such
time as Intel obtains actual knowledge of the facts giving rise to such claim. Nothing contained in this Section shall
limit other remedies otherwise available in law or in equity to Intel.
6. Non-solicitation and Misappropriation of Intel Trade Secrets.
I agree that for twelve (12) months after my employment ends, I will not solicit, directly or indirectly, any employee to
leave his/her employment with Intel. This applies to any employees that were employed with Intel as of my
separation date from the company. I further agree that I shall not use or disclose Intel Confidential Information to aid
any third party to target, identify, and/or solicit Intel employees to leave Intel employment and/or misappropriate Intel
trade secrets. I agree that any violation of this provision will result in immediate and irreparable injuries and harm to
Intel, and that Intel shall have the option of pursuing all available legal or equitable remedies, including injunctive
relief and specific performance. I understand that nothing in this Agreement prohibits me from disclosing my
compensation information to third parties in accordance with applicable law.
7. Computer Communications Are Not Private.
I acknowledge that use of Intel’s computer systems is not private or confidential. I understand and consent to
Intel’s right to review any communications to or from my work computer, pager, phone or other electronic device
and all computer information, including any password-protected employee communications, in accordance with
applicable law.
8. At-will Employment (U.S. only)
I acknowledge that my employment with Intel is “at-will” which means that both Intel and I have the right to
terminate my employment at any time, with or without advance notice and with or without cause. I understand
that if I become employed by an Intel entity outside the U.S., local employment and termination law will apply if
inconsistent with this Agreement.
9. Miscellaneous.
I understand that if Intel Corporation is not my employer, Intel Corporation is signing this Agreement as agent for the
Intel Corporation subsidiary, affiliate or successor that is my employer. The Agreement’s terms and conditions are
severable. If any part of this Agreement is found or held to be unenforceable in any jurisdiction in which this
Agreement is being performed, such provision shall be enforced to the greatest extent permitted by law, and the
remainder of this Agreement and such provision as applied to other persons, places or circumstances shall remain in
full force and effect. This Agreement: (a) survives my employment with Intel;
(b) inures to the benefit of successors and assigns of Intel; and (c) is binding upon my heirs, assigns, and legal
representatives. I am not a party to any other agreement which will interfere with my full compliance with this
Agreement, except as I have specifically identified in this Agreement. For U.S. employees, only a written agreement,
signed by the Vice-President, General Manager of Human Resources can change the “at will” nature of your
employment. The remainder of this Agreement may not be modified or amended except in writing, signed by the
parties. Only the Vice President, General Manager of Human Resources for Intel Corporation, or the General
Counsel of Intel Corporation, or their delegate, has the authority to sign an Agreement modifying the remainder of
this Agreement on behalf of Intel. This Agreement is effective the first day of my employment with Intel, and
supersedes any prior employee agreement signed by me with Intel, relating to this subject matter. I have carefully
read all of the provisions of this Agreement and I understand and will fully and faithfully comply with all provisions.
Intel Corporation
A. Douglas Melamed, Signature General Counsel
Employee
__________________________________/___________________ Printed Name & WWID #
(please print clearly)
_____________________________
Signature Date
Intel updated Rev. 1/2014
New Employee Orientation Certification
I, ______________________________, acknowledge receipt of the Intel Code of Conduct, Information
Security Business Code of Conduct and other employee materials. In addition to these documents, I
understand that the Intel Employment Guidelines provide a framework for workplace conduct and
expectations. The Intel Employment Guidelines cover:
About the Intel Employment Guidelines:
Important Information
Equal Employment Opportunity and
Diversity
Alcohol and Drug-Free Workplace
Non-Fraternization
Anti-harassment
Open Door
Attendance at Work
Progressive Discipline
Conducting Outside Business
Security and Confidential Information
Electronic Communications
Solicitation, Distribution and
Information-Posting
Employee Records and Information Requests
Workplace Behavior/Discipline and
Discharge
Employment At Will
Workplace Threats and Violence
I understand that I am expected to read and comply with the Intel Employment Guidelines which can be
found on Circuit (Intel’s internal website) under the My Life & Career Tab / My Career / Intel Employment
Guidelines. I acknowledge my obligation to review the Intel Employment Guidelines within the first
three weeks of my employment.
I understand and agree that nothing in the Intel Employment Guidelines, Code of Conduct, Information
Security Business Code of Conduct or other policies create an employment contract or other express
contractual obligations on the part of Intel. I also understand that Intel reserves the right to add,
modify, or delete provisions set out in these policies and guidelines at any time without advance notice.
I understand and agree that my employment is at will which means that either Intel or I have the right to
terminate my employment at any time, with or without advance notice and with or without cause. Only
a written agreement, signed by the Vice-President and Director of Human Resources, can change the
at-will nature of my employment.
I certify that I have read and understand the above.
_____________________________
PRINTED NAME
Intel updated Rev 11/2014
_______________________________
EMPLOYEE SIGNATURE
________________
WORLDWIDE ID
__________________
DATE
The Intel Retirement Plans
Prior Service Credit Questionnaire
New employees who have previously worked at an Intel Subsidiary in a contingent worker assignment as
an employee of a temporary employment or service agency may be eligible for Prior Service Credit under
the Intel Retirement Plans. Intel Subsidiaries include (but not limited to) McAfee, WindRiver, Havok.
This questionnaire should be used for prior service only.
If you cannot answer “Yes” to ALL of the below questions, you are not eligible for Prior Service Credit
and should not complete or submit this questionnaire.
I have performed service for an Intel Subsidiary while working as an employee of another
company e.g. employment or temporary agency (i.e.: Kelly Services, etc).
NOTE: - Independent contractors should answer “No”
- individuals employed directly for a company acquired by Intel should answer “No”
While working as an employee of another company (contingent worker), I reported to and was
directly managed in my daily activities by an Intel Subsidiary employee during the entire 365 day
period.
I worked for an Intel Subsidiary service agency or supplier for a minimum of 12 consecutive
(unbroken) months within the five years prior to my most current Intel Hire or Rehire date
If you answered “Yes” to ALL of the above questions, please complete remaining information below,
sign and return this form to: Prior Service Credit, Financial Benefits, FM3-224.
Your answers will help us verify (if required, you can provide proof of your eligibility information by W2 or other
means) and set up your eligibility for Prior Service Credit under the Intel Retirement Plans. Prior Service Credit will
be used to determine when you are eligible to participate in the Plans, and when future Intel contributions may be
made and will vest on your behalf.
Prior Service Credit Employee Eligibility Information
Please provide the following information regarding your employment with the temporary agency or service agency.
If you have worked for more than one agency, please use the back of this form for additional agency information.
Incomplete forms will not be processed
Agency Name: _____________________________________________________ (example: Kelly Services)
Address: ___________________________________________________________________________(street, city, state, zip)
Area Code and Phone #: _____________ Agency Contact Name:____________________________
Agency Employment Dates: From __ __ - __ __ - __ __ To __ __ - __ __- __ __
*Dates must include full MM-DD-YY or they will not be processed
Description of service you provided while an employee of this agency:
____________________________________________________________________________________
Name of Intel Subsidiary employee who managed you:_________________________________________
Describe how you were managed by the Intel Subsidiary employee: ______________________________
____________________________________________________________________________________
Signature - By signing below you are certifying that the above information is correct and if required, you can
provide proof of your eligibility information by W2 or other means.
Print Name: ______________________ Intel Mailstop ______________________ WWID____________________
Employee’s Signature _________________________________________________ Date_____________________
Additional Prior Service Credit Eligibility Information
Incomplete forms will not be processed.
____________________________________________________________________________________
____________________________________________________________________________________
Additional Prior Service Credit Eligibility Information
Incomplete forms will not be processed.
____________________________________________________________________________________
____________________________________________________________________________________
Intel Confidential rev. 1/1/2014
Welcome to Intel,
Part of getting started at Intel is to make critical benefits decisions for you and your family. If you are eligible, you are automatically enrolled in
the benefits described under Default Coverage below from your date of hire (except for Interns who default to no coverage). No action is
required by you unless you wish to select different plan options, waive (no coverage) coverage for yourself, or enroll your eligible dependents.
To research your options, costs, or to begin the enrollment process visit the My Health Benefits Web site; from Circuit, search for My Health
Benefits or from the Internet at www.intel.com/go/myben.
As a new hire I understand that:
√
√
√
I must take action within 30 days of my start date to either enroll or waive benefits for myself and any eligible dependents or I will be defaulted
into the coverage described below.

The next opportunity to change my benefits will be during annual enrollment or if I experience a change-in-status event (e.g.,
marriage, birth of a child). Enrollment for any change-in-status event must be completed within 30 days of the date of the event.
I must select the same medical and dental plan for my dependents as I do for myself.
The coverage I select will take effect back to my hire or rehire date.
I understand that my decision not to take action will result in the Default Coverage below:
√
√
I will be automatically enrolled in the Default Coverage which is the employee only coverage for medical (Anthem Blue Cross High Deductible
Health Plan) at a cost of $0 per month, dental (Delta Dental) at a cost of $2.00 per month and basic vision plan (VSP) for $1.00 per month
(except for Interns, who will default to no coverage)

You can change this default coverage by accessing the My Health Benefits Web site within the first 30 days from your hire or
rehire date.
Short-Term Disability (STD): STD provides financial assistance if I am unable to work due to illness, injury, or pregnancy. NOTE: CA, NJ,
NY, RI and HI make enrollment in STD mandatory.

If I live in CA, I will automatically be enrolled in the Intel California Voluntary Short Term Disability Plan (CA-VSTD) at a cost of
0.8% of wages to an annual maximum of $650.00. I understand I will be allowed to change to the CA state disability insurance
plan (CA-STD) at a higher cost (1.0% of wages to an annual maximum of $1016.36), but will not be allowed to completely opt out
of all plans. NOTE: The CA-VSTD provides richer coverage at a lower cost than the CA-SDI plan.

If I live in HI, I will be automatically enrolled in my state disability plan. I further understand that I will be auto-enrolled in the Intel
STD plan as supplement coverage at a combined state STD Plan and Intel STD Plan cost of 0.8% of wages to an annual
maximum of $604.68. You can only waive the supplemental default coverage by accessing the My Health Benefits Web site
within the first 30 days from your hire or rehire date.

If I live in NJ, I will be automatically enrolled in my state disability plan. I further understand that I will be auto-enrolled in the Intel
maximum of $608.46. You can only waive the supplemental default coverage by accessing the My Health Benefits Web site
within the first 30 days from your hire or rehire date.

If I live in NY, I will be automatically enrolled in my state disability plan. I further understand that I will be auto-enrolled in the Intel
maximum of $600. You can only waive the supplemental default coverage by accessing the My Health Benefits Web site within
the first 30 days from your hire or rehire date.

If I live in RI, I will be automatically enrolled in my state disability plan at a cost of 1.2% of wages to an annual maximum of
$752.40. You cannot waive this coverage.

If I live in any state not mentioned above, I will be automatically enrolled in the Intel STD plan at a cost of 0.8% of wages to an
annual maximum of $600. You can waive this default coverage by accessing the My Health Benefits Web site within the first 30
days from your hire or rehire date.
I understand the cost of medical, dental and disability coverage noted above are 2014 rates and are subject to change.
Notice of Special Enrollment Rights
If you are waiving enrollment in the Intel Group Health Plan for yourself or your dependents (spouse and children) because of other health
insurance coverage, you may in the future be able to enroll yourself and your dependents in the Intel Group Health Plan provided that you
request enrollment within 30 days after your other coverage ends. In addition, if you have a new dependent as a result of marriage, birth,
adoption, or placement for adoption, you may be able to enroll yourself and your dependent provided that you request enrollment within 30 days
after the marriage, birth, adoption, or placement for adoption. Additionally, you may be able to enroll yourself and your dependents in the Intel
Group Health Plan under these additional two scenarios:

You or your dependent(s) Medicaid or Children’s Health Insurance Program (“CHIP”) coverage is terminated as a result of loss of eligibility. You
must request this special enrollment for you and your dependent(s) within 60 days of the loss of coverage for Medicaid or CHIP.

You or your dependent(s) become eligible for a premium assistance subsidy* under Medicaid or CHIP. You must request this special enrollment
within 60 days of when eligibility for the premium assistance subsidy is determined.
* Note: States may elect to provide premium assistance subsidies to eligible, low-income children under a qualified employer-sponsored group health plan by
reimbursing employees for the difference in cost between the state plan and the employer’s plan. The Health FSA, CIGNA HDHP, and Anthem Blue Cross HDHP are
not considered a qualified employer sponsored group health plan.
___________________________
PRINTED NAME
______________________________
EMPLOYEE SIGNATURE
_______________
WWID
___________
DATE
NOTE: To begin the enrollment process or to find additional information on program costs, visit the My Health Benefits Web site; from Circuit, search for My Health
Benefits or from the Internet at www.intel.com/go/myben. If you have questions about your health benefits, benefit costs or enrolling, contact the Intel Health
Benefits Center at (877) GoMyBen (466-9236). For complete information on Intel’s Health and Disability programs visit the Pay, Stock and Benefits Handbook. From
Circuit, search for Pay, Stock and Benefits Handbook.
Intel Confidential
NEONHBensigform12/4/2013
Intel offers a New Hire Pay & Benefit course to all new hires. This course will provide an overview of the medical, dental, flexible spending accounts, life insurance,
disability, stock and retirement benefits offered by Intel. Following your Start Date, if you are interested in attending the course, please visit “Circuit > My Learning>
My Learning Tool”. In My Learning Search, type New Hire Pay, select Virtual Classroom (VC) from the drop down menu, check mark Match Exact Phrase and click
Search. Refine the search result by clicking Sites, selecting All sites and click Apply. The results will display the available offerings for the class. Click Register in the
offering that best suits your calendar. A registration confirmation will show up.
Intel Confidential
NEONHBensigform12/4/2013
Important information about medical care
if you have a work-related injury or illness
California law requires that Intel provide and pay for medical treatment if you are injured at work.
This medical care is provided by a Workers’ Compensation physician network called a Medical
Provider Network (MPN).
The following New Hire Notice describes your rights in choosing medical care for work-related
injuries and illnesses. It is your responsibility to read and understand this information. You may
download this document for your reference.
Please note that you may pre-designate your personal physician for work injuries as long as you
do so before sustaining an injury. The criteria for pre-designating your physician are:
•
•
•
You have previously received care with the physician,
Your physician is an M.D. or D.O., and
Your physician agrees to be your primary treating physician in the event of an injury.
If the criteria are not met, medical care will be provided through the MPN. More information
about how to pre-designate is included in the New Hire Notice below which includes a form to
complete to pre-designate a physician. If you chose this option, return the completed form to
your local Occupational Health Office.
California Occupational Health Office Locations
Folsom
FM2 – 1st Floor
Mon – Fri 8 a.m. – 5 p.m.
Phone: 916-356-5039
Fax:
916-356-6960
Santa Clara - Mission
In the link between SC9 and SC12
Mon – Fri 8 a.m. – 5 p.m.
Phone: 408-765-9587
Fax:
408-765-9010
For more information or to report a work-related injury, go to the Health and Wellness Programs
intranet site. To access the Health and Wellness Programs intranet site from Circuit, select the My
Life and Career tab, and under the My Health section select the Health and Wellness Programs
link, then select the Report a Workplace Illness or Injury link.
© Sedgwick CMS 2013 MH SB863 Page 1
New Hire Notice -- Injuries Caused By Work
What does workers’ compensation cover?
You may be entitled to workers' compensation benefits if
you are injured or become ill because of your job.
Workers' compensation covers most work-related physical
or mental injuries and illnesses. An injury or illness can be
caused by one event (such as hurting your back in a fall)
or by repeated exposures such as hurting your wrist from
doing the same motion over and over). Generally,
independent contractors, and volunteers who receive no
compensation are not covered by workers’ compensation
benefits.
Benefits:
Workers' compensation benefits include: Medical care,
temporary disability, permanent disability, supplemental
job displacement voucher, and death benefits
Medical Care:
Special rules apply if your employer offers a Health Care
Organization (HCO) or has a medical provider network.
You should receive information from your employer if you
are covered by an HCO or MPN. Contact your employer for
more information.
Treatment by your personal physician:
You may be treated by your personal physician if you
notify your employer prior to your injury. A personal
physician includes a medical group of licensed doctors of
medicine or osteopathy. Please have your physician
complete the attached form and return to your employer.
The following requirements must be met:
1.
2.
3.
4.
You are entitled to medical care that is reasonably
required to cure or relieve you from the effects of your
work-related injury. Medical care may include doctor visits,
hospital services, physical therapy, lab tests, x-rays, and
medicines that are reasonably necessary to treat your
injury. Providers should never bill you directly for workrelated injuries. There is a limit on some medical services.
Your employer is required to provide you with a claim form
within one business day of learning about your injury. It is
extremely important that you complete the “Employee”
section of the claim form as your employer is required to
authorize medical care within one working day after you
file the form. If additional care is necessary after the initial
treatment, the claims administrator will authorize any care
that is appropriate for your injury, including the referral to
specialists.
Your Primary Treating Physician (PTP):
This is the doctor with overall responsibility for treating
your injury or illness. The primary treating physician
determines what type of treatment you need and when
you may return to work. A multispecialty medical group of
licensed doctors and osteopathy can be designated as
personal physicians. If your employer or your employer’s
insurer does not have a Medical Provider Network, you
may be able to change your treating physician to your
personal chiropractor or acupuncturist following a workrelated injury or illness by making a request to the claims
administrator. Chiropractors may not continue as the
primary treating physician after 24 visits. If specialists,
diagnostics, etc. are needed in your case, this physician
will be responsible for making the referrals. If you name
your personal physician before your injury, you may see
him or her for treatment in certain circumstances.
Otherwise, your employer has the right to select the
physician who will treat you for the first 30 days. You may
be able to switch to a doctor of your choice after 30 days.
Your employer must offer group health coverage
Your personal physician must agree in advance to
treat you for any work injuries or illnesses
Your physician must be your regular physician and
surgeon.
Your physician has previously directed your medical
treatment and retains your records, including your
medical history.
What happens if your employer disputes your
injury?
State law requires employers to authorize medical care
within one working day of receiving a DWC 1 claim form.
Your employer may be liable for as much as $10,000 in
medical care until your claim is accepted or denied.
Medical Provider Networks:
Your employer may be using a MPN, which is a selected
network of health care providers to provide treatment to
workers injured on the job. If your employer is using a
MPN, a MPN notice should be posted next to this poster to
explain how to use the MPN. You can request a copy of
this notice by calling the MPN number below. If you have
predesignated your personal physician prior to your work
injury, then you may receive treatment from your
predesignated doctor. If you have not predesignated and
your employer is using a MPN, you are free to choose an
appropriate provider from the MPN list after the first
medical visit directed by the employer. If you are treating
with a non-MPN doctor for an existing injury, you may be
required to change to a doctor within the MPN. For more
information see the MPN contact information below
Current MPN toll free number: 800-625-6588
MPN Website: www.harborsys.com/sedgwick2
1. Go to www.harborsys.com/sedgwick2
2. Enter location information or specific provider
information in the “Provider Search” box
3. Select the appropriate medical disciplines from the
“Filter by specialty” drop menu
© Sedgwick CMS 2006 Page 2
Permanent Disability (PD) Benefits:
4. Click the blue “Search” button when ready
Current MPN Address:
Sedgwick CMS
10690 White Rock Road Suite 100
Rancho Cordova, CA 95670
MPN Effective Date: ___6/9/2014_______________
What if my employer has a Medical Provider
Network?
Please see the attached Medical Provider
Employee Notification.
Network
What if my employer does not have a Medical
Provider Network?
If your employer does not have a Medical Provider
Network, you may be able to change your treating
physician to your personal chiropractor or acupuncturist
following a work-related injury or illness within 30 days of
reporting your injury. You may use the attached Notice of
Personal Chiropractor or Personal Acupuncturist form to
notify your employer of this change.
You may be entitled to payments if your physician says
your injury has limited your ability to work. The permanent
disability rate is calculated by multiplying your average
weekly wage by two thirds, subject to statutory minimums
and maximums. The amount of permanent disability or
impairment may depend on your doctor’s opinion, as well
as your age, occupation type of injury and date of injury.
If you have permanent disability or your claims examiner
suspects you have permanent disability, a letter will be
sent to you explaining your benefits, including the estimate
or total value of permanent disability, weekly payment
amount, how the benefit was calculated, and all of your
related rights under the California Labor Code, including
your right to object to the report upon which the
determination is being based. Permanent Disability
benefits are payable within 14 days of the last payment of
temporary disability benefits or after you physician
indicates there is permanent disability. The benefit is
payable every fourteen days.
Supplemental Job Displacement Benefit:
If you need first aid treatment, contact your employer. If
you have more than a simple first aid injury, you will need
to ask your employer for a claim form.
You may be entitled to a nontransferable voucher payable
to a state approved school. To qualify, your injury must
result in a permanent impairment and your employer is
unable to offer modified or alternative work within 60 days
of receipt of a report asserting that all medical conditions
have reached maximum medical improvement. If your
employer does not offer a modified or alternate job within
60 days of determination of maximum medical
improvement, you may chose to receive a nontransferable
voucher to use at a state accredited school for educationrelated retraining or skill replacement. If you qualify for
the supplemental job displacement benefit, your claims
examiner will provide a voucher for up to $6,000.00.
Temporary Disability (TD) Benefits:
Return to Work Fund
You may be entitled to payments if you lose wages while
recovering. Your temporary disability rate is calculated by
multiplying your average weekly wage by two thirds. The
first 3 days of disability are not payable under California
law unless there is hospitalization at the time of injury or
the disability exceeds 14 days. If your physician returns
you to work on a modified basis, you may be entitled to
wage loss. This is generally calculated by multiplying the
difference between your average weekly wage and your
earnings during modified duties times two thirds. This is
subject to the benefit minimums and maximums set by the
California Legislature. Temporary disability benefits are
payable within 14 days of the date of injury or knowledge
of the injury. Subsequent payments are due every 14
days. For injuries occurring on or after 1/1/08, no more
than 104 weeks of temporary disability are payable within
5 years from the date of injury. For longer term conditions
(hepatitis B &C, amputations, severe burns, HIV, high
velocity eye injuries, chemical burns to the eyes,
pulmonary fibrosis, and chronic lung disease) no more
than 240 weeks within five years from the date of injury
are payable. You may be eligible for state disability
benefits from the Employment Development Department
(EDD) if TD benefits are stopped, delayed, or denied.
There are time limits so contact EDD for more information.
If your injury results in permanent impairment and it is
determined that the amount awarded is disproportionately
low in comparison to your loss of earnings, you may be
entitled to additional compensation.
A fund was
established to supplement permanent impairment benefits
under specific circumstances. This fund is administered
by the Division of Workers Compensation. Your examiner
can assist in directing you to the correct resource to
determine eligibility.
Emergency Medical Care:
If you need emergency care, call 911 for help immediately
from the hospital, ambulance, fire department or police
department.
First Aid:
Death Benefits:
Death benefits are paid to dependents of a worker who
dies from a work-related injury or illness. The benefit is
calculated and paid in the same manner as temporary
disability. This benefit is paid at a minimum rate of $224
per week. The death benefit rates are set by state law and
the amount depends upon the number of dependents. If
dependent minor children are involved, death benefits are
payable at least until the youngest child reaches majority
age. Burial expenses are also provided under this benefit.
Report Your Injury:
Report the injury immediately to your supervisor or to:
Employer representative: Occupational Health Clinic
Phone number:
Folsom: (916) 356-5039
Santa Clara: 408) 765-9587
After Hours: Company Nurse 877-854-6877
______________________________________________
Don't delay. There are time limits. If you wait too long,
you may lose your right to benefits. Your employer is
required to provide you a claim form within one working
day after learning about your injury. Within one working
day after you file a claim form, your employer shall
authorize the provision of all treatment, consistent with
the applicable treating guidelines, for your alleged injury
and shall be liable for up to ten thousand dollars ($10,000)
in treatment until the claim is accepted or rejected. Until
the date the claim is accepted or rejected, liability for
medical treatment shall be limited to ten thousand dollars
($ 10,000). If your claim is denied, you have the right to
appeal the decision within one year of the date of injury.
Discrimination:
It is illegal for your employer to punish or fire you for
having a work injury or illness, for filing a claim, or
testifying in another person's workers' compensation case.
If proven, you may receive lost wages, job reinstatement,
increased benefits, and costs and expenses up to limits set
by the state.
Labor Commissioner at the Division of Labor Standards
Enforcement - their number can be found in your local
White Pages under California State Government,
Department of Industrial Relations.
You can get free information from a State Division of
Workers' Compensation Information & Assistance Officer.
The nearest Information & Assistance Officer is at:
Address: See attached form
City: _________________ Phone: ____________________
Hear recorded information and a list of local offices by
calling toll-free (800) 736-7401.
Learn more online: www.dir.ca.gov.
False claims and false denials:
Any person who makes or causes to be made any
knowingly false or fraudulent material statement or
material representation for the purpose of obtaining or
denying workers' compensation benefits or payments is
guilty of a felony and may be fined and imprisoned.
Your employer may not be liable for the payment of
workers’ compensation benefits for any injury that arises
from your voluntary participation in any off-duty
recreational, social, or athletic activity that is not part of
your work-related duties.
Questions?
If you have questions, see your employer or the claims
examiner who handles workers' compensation claims for
your employer.
Claims Administrator:
Sedgwick Claims Management Services, Inc.
Address: P.O. Box 14152 ___________________________
City: Lexington_______ State: __KY_____Zip: 40512-4152
Phone: 925-598-6980 ______________________________
The employer is insured for workers’ compensation by:
Self Insured
_______________________________________________
How do I locate information regarding my
employer’s current workers’ compensation carrier?
For information regarding your employer’s workers’
compensation carrier, please visit the below website.
https://www.caworkcompcoverage.com
If the workers’ compensation policy has expired, contact a
PREDESIGNATION OF PERSONAL PHYSICIAN
In the event you sustain an injury or illness related to your employment, you may be treated for such injury
or illness by your personal medical doctor (M.D.) or doctor of osteopathic medicine (D.O.) if:
You must have group health coverage for non-industrial injuries or illnesses from any source;
The doctor is your regular physician, who shall be either a physician who has limited his or her practice of
medicine to general practice or who is a board-certified or board-eligible internist, pediatrician, obstetriciangynecologist, or family practitioner, and has previously directed your medical treatment, and retains your
medical records;
Your "personal physician" may be a medical group if it is a single corporation or partnership composed of
licensed doctors of medicine or osteopathy, which operates an integrated multispecialty medical group
providing comprehensive medical services predominantly for non-occupational illnesses and injuries;
Prior to the injury your doctor agrees to treat you for work injuries or illnesses;
Prior to the injury you provided your employer the following in writing: (1) notice that you want your
personal doctor to treat you for a work-related injury or illness, and (2) your personal doctor’s name and
business address.
You may use this form to notify your employer if you wish to have your personal medical doctor or a doctor
of osteopathic medicine treat you for a work- related injury or illness and the above requirements are met.
Return the completed form to your site Occupational Health Office.
NOTICE OF PREDESIGNATION OF PERSONAL PHYSICIAN Employee:
Complete this section.
TO: (name of employer). If I have a work-related injury or illness, I choose to be treated by:
(name of doctor) (M.D., D.O.)
(street address, city, state, ZIP)
(telephone number)
Employee Name (please print): ___________________________________________________
Employee’s Address: ___________________________________________________________
Employee’s Signature: _____________________________________________________ Date: _________
Physician: I agree to this pre-designation:
Signature: ________________________________________________________________ Date: _________
(physician or designated employee of the physician)
The physician is not required to sign this form, however, if the physician or designated employee of the
physician does not sign, other documentation of the physician’s agreement to be pre-designated will be
required pursuant to Title 8, California Code of Regulations, section 9780.1 (a)(3).
MPN Employee Implementation Notification
“Unless you pre desígnate a physician or medical group, your new work injuries arising on or after 6/9/2014
will be treated by providers in the Sedgwick/Harbor2 MPN. If you have an existing injury, you may be
required to change to a provider in the new MPN. Check with your claims adjuster. You may obtain more
information about the MPN from the workers’ compensation poster or from your employer.”
© Sedgwick CMS 2013 MH SB863 Página 6
Notificación de nueva contratación –
Lesiones ocasionadas en el trabajo
¿Qué cubre la indemnización por accidentes
laborales?
los quiroprácticos no pueden seguir siendo médicos primarios
de tratamiento. Si en su caso son necesarios especialistas,
Es posible que usted tenga derecho a los beneficios de
indemnización por accidentes laborales si se lesiona o
enferma a causa de su trabajo. La indemnización por
accidentes laborales cubre la mayoría de las lesiones
físicas o mentales relativas al trabajo, así como las
enfermedades laborales. Una lesión o una enfermedad
puede ser provocada por un suceso (como lastimarse la
espalda al caerse) o por repetidas exposiciones, como al
lastimarse la muñeca por estar haciendo el mismo
movimiento una y otra vez. Por lo general, los contratistas
independientes y los voluntarios que no reciben una
remuneración no tienen la cobertura de beneficios de
indemnización por accidentes laborales.
diagnósticos, etc., este médico será el responsable de
hacer las derivaciones correspondientes. Si usted designa
a su médico particular antes de que ocurra la lesión, en
algunas circunstancias podrá consultarlo para obtener
tratamiento. De lo contrario, su empleador tiene derecho a
elegir al médico que le dará tratamiento durante los
primeros 30 días. Después de 30 días usted podrá cambiar
e ir con el médico de su preferencia. Aplican reglas
especiales si su empleador le ofrece una Organización de
Atención Médica (HCO) o si cuenta con una Red de
Proveedores de Atención Médica (MPN). Usted deberá
recibir información por parte de su empleador si cuenta
con cobertura de una HCO o una MPN. Para más
información, consulte a su empleador.
Beneficios:
Tratamiento por parte de su médico particular:
Entre los beneficios de indemnización por accidentes
laborales están: Atención médica, discapacidad temporal,
discapacidad permanente, vale de beneficio suplementario
por desplazamiento de trabajo y beneficios a causa de
fallecimiento.
Su médico particular puede darle tratamiento si usted se lo
notifica a su empleador antes de que ocurra una lesión. El
médico particular también puede ser un grupo de médicos
u osteópatas con licencia. Por favor pídale a su médico
que llene el formulario adjunto y que se lo devuelva a su
empleador. Se deben cumplir los siguientes requisitos:
Atención médica:
Usted tiene derecho a recibir la atención médica que
razonablemente se requiera para curarle o aliviarle los
efectos de su lesión laboral. La atención médica puede
incluir las consultas al médico, servicios hospitalarios,
terapia física, análisis de laboratorio, radiografías y
medicamentos que sean razonablemente necesarios para
dar tratamiento a su lesión. Los proveedores nunca
deberán cobrarle a usted directamente cuando se trate de
lesiones laborales. Existe cierto límite en cuanto a algunos
servicios médicos. Su empleador tiene la obligación de
darle un formulario de reclamación en un lapso de un día
hábil a partir de que se entere de su lesión. Es sumamente
importante que en el formulario de reclamación usted llene
la sección “Empleado”, ya que a su empleador se le exige
que autorice la atención médica en un lapso de un día
hábil a partir de que usted presente el formulario. En caso
de que sea necesaria atención adicional después del
tratamiento inicial, el administrador de reclamaciones
autorizará lo que sea apropiado para su lesión, inclusive, la
derivación a especialistas.
Su Médico Primario de Tratamiento (PTP):
Se trata del médico con la responsabilidad general de darle
tratamiento a su lesión o enfermedad. Su médico primario
de tratamiento determina qué tipo de tratamiento necesita
y cuándo podrá regresar a su trabajo. Como médico
personal se puede designar a un grupo con diversas
especialidades de médicos y osteópatas con licencia. Si su
empleador o la compañía aseguradora de su empleador no
tienen una Red de Proveedores de Atención Médica, usted
puede cambiar al médico que lo atienda por su
quiropráctico o acupunturista después de una lesión o
enfermedad laboral si presenta una solicitud al
administrador de reclamaciones. Después de 24 consultas,
1.
2.
3.
4.
Su empleador debe ofrecer seguro médico
colectivo.
Su médico particular debe estar de acuerdo
previamente en darle tratamiento por lesiones o
enfermedades laborales.
Su médico debe ser su médico de cabecera y
cirujano.
Su médico previamente se ha encargado de su
tratamiento y conserva sus registros, inclusive su
historial médico.
¿Qué sucede si su empleador cuestiona la lesión?
La ley estatal exige que su empleador autorice atención
médica en un lapso de un día a partir de que reciba el
formulario de reclamación DWC 1. Su empleador puede
ser responsable de hasta $10,000 en atención médica
hasta que la reclamación sea aceptada o rechazada.
Redes de Proveedores de Atención Médica:
Puede ser que su empleador utilice una MPN, la cual es
una red seleccionada de proveedores de atención médica
que se encargan de dar tratamiento a los trabajadores que
se lesionan o enferman en el trabajo. Si su empleador
cuenta con una Red de Proveedores de Atención Médica,
junto a este cartel deberá exhibir un aviso en el que se
explique cómo se hace uso de dicha red. Usted puede
solicitar una copia de este aviso si llama al número de la
Red de Proveedores de Atención Médica que aparece más
abajo. Si usted ha designado previamente a su médico
particular antes de que ocurra una lesión laboral, entonces
puede recibir tratamiento con dicho médico. Si no lo ha
designado previamente y su empleador cuenta con una
Red de Proveedores de Atención Médica, usted estará en
libertad de elegir de la MPN al proveedor adecuado
© Sedgwick CMS 2010 Página 7
después de la primera consulta médica que su empleador
haya indicado. Si para una lesión actual usted recibe
tratamiento de un médico que no pertenezca a la Red de
Proveedores de Atención Médica, es posible que se
requiera que cambie de médico a alguno que sí forme
parte de la red. Para más información consulte la
información de contacto de la Red de Proveedores de
Atención Médica a continuación:
Fecha en que entra en vigor la MPN:
Es posible que usted tenga derecho a pagos si pierde su
salario mientras se recupera. La tarifa por discapacidad
temporal se calcula multiplicando su salario semanal
promedio por dos tercios. Según la ley de California, los 3
primeros días de incapacidad no se pagan, a menos que
haya hospitalización al momento de la lesión o que la
incapacidad sea por más de 14 días. Si su médico lo
regresa a trabajar con modificaciones, es posible que
tenga derecho a pérdida de salario. Generalmente esto se
calcula al multiplicar por dos tercios la diferencia entre su
salario semanal promedio y sus ingresos durante el tiempo
que desempeñe el trabajo modificado. Esto está sujeto al
mínimo y máximo de beneficios estipulados por la
Legislatura de California. Los beneficios por discapacidad
temporal son pagaderos dentro de los 14 días después de
la fecha de la lesión o de que se sepa de la lesión. Los
pagos posteriores son cada 14 días. Las lesiones que
hayan ocurrido el 1 de enero de 2008 o después, sin
exceder 104 semanas de discapacidad temporal, son
pagaderas en un lapso de 5 años a partir de la fecha de la
lesión. Las afecciones a más largo plazo (como hepatitis B
y C, amputaciones, quemaduras graves, VIH, lesiones
oculares por alta velocidad, quemaduras en los ojos por
sustancias químicas, fibrosis pulmonar y enfermedades
crónicas de los pulmones) son pagaderas no más de 240
semanas en un lapso de cinco años a partir de la fecha de
la lesión. Es posible que usted reúna los requisitos para
recibir beneficios estatales por incapacidad por parte del
Departamento de Desarrollo del Empleo (EDD) si los
beneficios por discapacidad temporal se suspenden, se
demoran o se niegan. Existen límites de tiempo, por lo
tanto, para más información comuníquese al EDD.
4/15/2014
Beneficios por discapacidad permanente (PD):
Número telefónico gratuito de la Red de
Proveedores de Atención Médica actual: 800-6256588
Sitio web de la MPN:
www.harborsys.com/sedgwick2
1.
2.
3.
4.
Ir a www.harborsys.com/sedgwick2
Ingrese la información de ubicación o información
específica del proveedor en la "Búsqueda de
Proveedores" caja
Seleccione las disciplinas apropiadas médicos del
"Filtro por especialidad" menú desplegable
Haga clic en el azul "Buscar" cuando esté listo
Dirección de la Red de Proveedores de Atención
Médica actual:
Sedgwick CMS
10690 White Rock Road Suite 100
Rancho Cordova, CA 95670
¿Y si mi empleador cuenta con una Red de
Proveedores de Atención Médica?
Consulte la Notificación para los Empleados sobre la Red
de Proveedores de Atención Médica que se anexa.
¿Y si mi empleador no cuenta con una Red de
Proveedores de Atención Médica?
Si su empleador no tiene una Red de Proveedores de
Atención Médica, usted puede cambiar al médico que lo
atienda por su quiropráctico o acupunturista después de
una lesión o enfermedad laboral en un lapso de 30 días a
partir de que reporte la lesión. Puede usar el formulario
anexo de Notificación al Quiropráctico o Acupunturista
Personal para notificar a su empleador sobre este cambio.
Atención médica de emergencia:
Si necesita atención médica de emergencia, llame
inmediatamente al 911 para recibir ayuda del hospital,
ambulancia, departamento de bomberos o de la policía.
Primeros auxilios:
Si necesita primeros auxilios, avise a su empleador. Si
tiene más que una lesión simple que requiera primeros
auxilios, necesitará pedir a su empleador un formulario de
reclamación.
Beneficios por discapacidad temporal (TD):
Usted puede tener derecho a recibir pagos si su médico
determina que su lesión ha limitado su capacidad para
trabajar. La tarifa por discapacidad permanente se calcula
al multiplicar su salario semanal promedio por dos tercios
y está sujeta al mínimo y máximo establecidos por la ley.
La cantidad por discapacidad o impedimento permanente
puede depender de la opinión de su médico, así como de
su edad, tipo de lesión según su ocupación y la fecha de la
lesión. Si usted tiene una discapacidad permanente o su
evaluador de reclamaciones sospecha que la tenga, se le
enviará una carta en la que le expliquen sus beneficios,
incluirá el cálculo o el valor total de la discapacidad
permanente, la cantidad de pago semanal, cómo se calcula
el beneficio y todos sus derechos respectivos conforme al
Código del Trabajo de California, e inclusive su derecho a
objetar el informe sobre el cual se basa la resolución. Los
beneficios por discapacidad permanente son pagaderos en
un lapso de 14 días a partir del último pago de beneficios
por discapacidad temporal o después de que su médico
haya indicado que existe una discapacidad permanente. El
beneficio es pagadero cada 14 días.
Beneficio suplementario por desplazamiento de
trabajo:
Usted puede tener derecho a un vale no transferible pagadero
a una escuela estatal aprobada. Para cumplir con los
requisitos, su lesión debe causarle una incapacidad, y además
no ser posible que su empleador le ofrezca un trabajo
modificado o alternativo en un lapso de 60 días a partir de que
reciba el reporte que indique que todas las afecciones han
llegado al máximo de la mejoría médica. Si su empleador no le
ofrece un empleo modificado o alternativo en un lapso de 60
días a partir de que se determine la máxima mejoría médica,
usted puede optar por recibir un vale no transferible para que
lo utilice en una escuela acreditada por el estado para que
tome cursos de readiestramiento o de reemplazo de destrezas.
Si reúne los requisitos para el beneficio suplementario por
desplazamiento de trabajo, su evaluador de reclamaciones le
dará un vale de hasta $6,000.00.
Discriminación:
Es ilegal que su empleador lo castigue o lo despida por
tener una lesión o enfermedad laboral, por presentar una
reclamación o por declarar en el caso de indemnización
por accidentes laborales de otra persona. Si se comprueba,
usted puede recibir el salario que haya perdido, una
reincorporación a su empleo, mayores beneficios y las
costas y gastos hasta los límites establecidos por el
estado.
Fondo para el regreso al trabajo
Si su lesión da como resultado una incapacidad permanente y
se
determina
que
la
cantidad
otorgada
es
desproporcionadamente baja en comparación con su pérdida
de ingresos, puede tener derecho a una indemnización
adicional. Se ha establecido un fondo para complementar los
beneficios por discapacidad permanente en circunstancias
específicas. Ese fondo está administrado por la División de
Indemnización por Accidentes Laborales. Su evaluador puede
ayudarle para que se dirija al recurso correcto para determinar
su elegibilidad.
Beneficios por muerte:
Los beneficios por fallecimiento se pagan a los
dependientes de un trabajador que muera a consecuencia
de una lesión o enfermedad laboral. Este beneficio se
calcula y paga de la misma manera que la discapacidad
temporal. Se paga a una tarifa mínima de $224 a la
semana. Las tarifas del beneficio por fallecimiento son
estipuladas por las leyes estatales y el monto será según el
número de dependientes. Si hay niños menores
dependientes, los beneficios por fallecimiento son
pagaderos por lo menos hasta que el hijo o la hija menor
lleguen a la mayoría de edad. Con este beneficio se cubren
también los gastos funerarios.
Notifique su lesión.
Informe de inmediato a su supervisor sobre la lesión o al:
______________________________________________
Representante del Empleador Teléfono:
______________________________________________
No demore. Hay límites de tiempo. Si espera demasiado
tiempo, es posible que pierda el derecho a sus beneficios.
Su empleador tiene la obligación de darle un formulario de
reclamación en un lapso de un día hábil a partir de que se
entere de su lesión. En un lapso de un día hábil a partir de
que usted presente el formulario de reclamación, su
empleador habrá de autorizar que se le proporcione todo
tratamiento que sea congruente con las pautas
correspondientes de tratamiento por su supuesta lesión y
será responsable hasta por $10,000 (diez mil dólares) de
tratamiento hasta que la reclamación haya sido aceptada o
rechazada. Hasta la fecha cuando la reclamación sea
aceptada o rechazada, la responsabilidad de tratamiento
médico se limitará a $10,000 (diez mil dólares). Si le
rechazan su reclamación, usted tendrá derecho a apelar la
decisión en un lapso de un año a partir de la fecha de la
lesión.
¿Preguntas?
Si tiene alguna pregunta, consulte a su empleador o al
evaluador de reclamaciones correspondiente que se
encargue de las reclamaciones de indemnización por
accidentes laborales.
Administrador de Reclamaciones:
Sedgwick Claims Management Services, Inc.
Dirección: P.O. Box 14152 __________________________
Ciudad: Lexington __Estado: _KY______C.P.: _40512-4152
Teléfono: 925-598-6980 ___________________________
El empleador está asegurado para indemnización por
accidentes laborales con: Self Insured
¿Cómo encuentro información acerca de la
aseguradora actual de mi empleador para la
indemnización por accidentes laborales?
Para tener información sobre la aseguradora de su empleador
para la indemnización por accidentes laborales, visite el
siguiente sitio Web:
https://www.caworkcompcoverage.com
Si la póliza de indemnización por accidentes laborales ha
caducado, comuníquese con un Comisionado del Trabajo
en la División para el Cumplimiento de las Normas
Laborales; el número se puede encontrar en las Páginas
Blancas locales, en Gobierno del Estado de California,
Departamento de Relaciones Industriales.
Podrá obtener información gratuita con un funcionario de
Información y Asistencia de la División Estatal de
Indemnización al Trabajador.
El funcionario de Información y Asistencia más cercano se
encuentra en:
Dirección: ver formulario adjunto
Ciudad: ______________ Estado: _______C.P.: _________
Llame al (800) 736-7401, escuche la información
grabada y una lista de oficinas locales. Entérese de más en
línea: www.dir.ca.gov.
encarcelada.
Reclamaciones falsas y negativas falsas.
Toda persona que deliberadamente haga o provoque que
se hagan declaraciones materiales falsas o fraudulentas
con el propósito de obtener o de que se rechace una
indemnización por accidentes laborales o pagos, será
culpable de un delito grave y podrá ser multada y
Su patrón puede no ser responsable de pagar la
indemnización por accidentes laborales que sean
consecuencia de que usted participe voluntariamente en
alguna actividad fuera de su horario de trabajo en
actividades recreativas, sociales o atléticas que no formen
parte de sus deberes laborales.
DESIGNACIÓN PREVIA DE UN MÉDICO PARTICULAR
En caso de que usted sufra una lesión o enfermedad laboral, puede ser tratado por su médico particular o
por su médico osteópata si:

Usted debe tener la cobertura de salud de grupo para las lesiones no industriales o enfermedades de
cualquier origen;

El médico es su médico particular, el cual debe ser doctor en medicina y haya limitado su práctica a la
medicina general o que sea internista certificado por el Consejo Médico o prospecto para dicha
especialidad, o pediatra, ginecólogo-obstetra o médico familiar y que anteriormente haya estado a cargo
de su tratamiento médico y tenga en su haber sus registros médicos

Su “médico particular” puede ser un grupo médico si se trata de una sola sociedad o una asociación
formada por doctores en medicina u osteopatía con licencia, la cual opere un grupo médico integrado
con varias especialidades y ofrezca servicios médicos integrales predominantemente para lesiones y
enfermedades no laborales

Antes de la lesión, su médico está de acuerdo en tratarlo por lesiones o enfermedades laborales

Antes de la lesión, usted entregó por escrito lo siguiente a su empleador: (1) notificación de que desea
que su médico particular lo trate por una lesión o enfermedad laboral y (2) el nombre y la dirección del
consultorio de su médico particular.
Deberá usar este formulario para avisar a su empleador si desea que su propio médico o su doctor en
osteopatía le den tratamiento debido a una lesión o enfermedad laboral y si se reúnen los requisitos
anteriores.
NOTIFICACIÓN DE DESIGNACIÓN PREVIA DE MÉDICO PARTICULAR
Empleado: Llene esta sección.
PARA: (nombre del empleador). Si tengo una lesión o enfermedad laboral, opto por ser tratado por:
(Nombre del doctor) (en medicina u osteopatía)
(dirección, ciudad, estado, Código Postal)
(teléfono)
Nombre del empleado (en letra de imprenta): _____________________________
Dirección del empleado: ______________________________________________________
Firma del empleado ___________________________________________________ Fecha:_______________
Médico: Estoy de acuerdo con esta designación previa:
Firma: ______________________________________________________________ Fecha:_______________
(Médico o empleado designado del médico)
Según el Título 8 del Código de Normatividad de California, artículo 9780.1(a)(3), no se requiere que el
médico firme este formulario, sin embargo, si el médico o empleado designado del médico no lo firma, se
requerirá otra documentación que avale que el médico acepta ser designado.
FORMULARIO DWC 9783 (1 de marzo de 2007)
Empleado MPN Aplicación de notificación
“A menos que usted haya designado previamente a un médico o grupo médico, las nuevas lesiones laborales
que se presenten el 6/9/2014 o posteriormente serán tratadas por los proveedores de la red de atención médica
Sedgwick/Harbor2 MPN. Si usted tiene una lesión, es posible que se requiera que cambie a un médico de la
nueva Red de Proveedores de Atención Médica. Consulte a su perito de seguros. En el cartel sobre
indemnización por accidentes laborales puede obtener más información sobre la Red de Proveedores de
Atención Médica o con su empleador.”
California Division of Workers’ Compensation
Information & Assistance Unit Directory
Anaheim
1065 N.
PacifiCenter Drive
Anaheim 928062141
(714) 414-1801
Oakland
1515 Clay Street,
6th floor
Oakland, CA
94612-1519
(510) 622-2861
Bakersfield
1800 30th Street,
Suite 100
Bakersfield, CA
93301-1929
(661) 395-2514
Oxnard
1901 N. Rice Ave.,
Ste. 200
Oxnard, CA
93030-7912
(805) 485-3528
Eureka
100 "H" Street,
Room 202
Eureka, CA
95501-0481
(707) 441-5723
Pomona
732 Corporate
Center Drive
Pomona, CA
91768-2653
(909) 623-8568
Fresno
2550 Mariposa
Mall,
Room 2035
Fresno, CA
93721-2219
(559) 445-5355
Goleta
6755 Hollister
Avenue,
Room 100
Goleta, CA 931175551
(805) 968-4158
Long Beach
300 Oceangate
Street,
Suite 200
Long Beach, CA
90802-4304
(562) 590-5240
Los Angeles
320 W. 4th Street,
9th floor
Los Angeles, CA
90013-1954
(213) 576-7389
Redding
2115 Civic Center
Drive
Room 15
Redding, CA
96001-2740
(530) 225-2047
Riverside
3737 Main Street,
Room 300
Riverside, CA
92501-3337
(951) 782-4347
Marina del Rey
4720 Lincoln Blvd
2nd floor
Marina del Rey,
CA 90292-6902
(310) 482-3820
Sacramento
160 Promenade
Circle,
Suite 300
Sacramento, CA
95834-2962
(916) 928-3158
Salinas
1880 North Main
Street,
Suite 100
Salinas, CA
93906-2037
(831) 443-3058
San Bernardino
464 W. Fourth
Street,
Suite 239
San Bernardino,
CA 92401-1411
(909) 383-4522
San Diego
7575 Metropolitan
Drive,
Suite 202
San Diego, CA
92108-4424
(619) 767-2082
San Francisco
455 Golden Gate
Avenue,
2nd floor
San Francisco, CA
94102-7014
(415) 703-5020
San Jose
100 Paseo de San
Antonio,
Room 241
San Jose, CA
95113-1402
(408) 277-1292
San Luis Obispo
4740 Allene Way,
Suite 100
San Luis Obispo,
CA 93401-8736
(805) 596-4159
Santa Ana
605 W Santa Ana
Blvd, Bldg 28
Room 451
Santa Ana, CA
92701-4070
(714) 558-4597
Santa Rosa
50 "D" Street,
Room 420
Santa Rosa, CA
95404-4771
(707) 576-2452
Stockton
31 East Channel
Street,
Room 344
Stockton, CA
95202-2314
(209) 948-7980
Van Nuys
6150 Van Nuys
Blvd.,
Room 105
Van Nuys, CA
91401-3370
(818) 901-5367
Data Protection Authorization for New Hires
Congratulations on your recent internship or employment with Intel. As part of our new hire paperwork, we
request that you read the following authorization and check the appropriate box below.
Some of the information you are submitting to Intel may be considered personal information and governed by data
protection laws. Intel is committed to complying with applicable data protection laws. As a result, we hereby obtain
your authorization to collect, use, store and transfer your personal information to our global employee database
currently located in California, U.S.A. For some specific applications, such as email services, Intel utilizes cloud
computing technology. Intel will not sell or rent your personal information to third parties without your explicit
consent. We do use third party vendors to provide services on behalf of Intel (for a complete list of those vendors
and the services they provide, please contact Intel HR). These vendors have met our requirements for data
protection compliance. Your personal information will be controlled with access limited to those Intel employees or
vendors contracted by Intel who have a business need to access your personal information. Access rights may
include human resources personnel, your managers and their designees, IT, and limited number third party service
providers responsible for administering your benefits. Access to your personal information will include the
following purposes:
1)
2)
3)
4)
5)
6)
7)
8)
9)
10)
11)
12)
13)
14)
15)
16)
Management of the internship or employment relationship – demographic information such as home
address, telephone number, email address, or legally required information such as social security number,
national identification number or its equivalent, and country of citizenship, birth date and gender;
Training and career development – information pertaining to education, skills, certifications, training
requirements, training history, course completed/needed, performance evaluations/reviews;
Program participation - information needed for enrolment and/or administration of special programs
offered by Intel such as benefits, training programs, succession planning, and any other program you
specifically join;
Management of IT and Facilities Services to include office, telephone, email, and computer equipment,
services and access rights;
Payroll processing - using information such as your salary, bank account details, total deductions,
allowances, etc.;
Intel to know where you work, your work hours, and how you spend your work time - using information
such as work location, job title, supervisor, cost center time/absence records etc.;
Support for your technical resource needs, including support of your computer and communications
hardware and software, through Intel’s Technical Assistance Center.
Participation in core HR processes - using information such as performance rating, merit increase, job
grade, competencies, development plan, general pay awards, training programs, stock, etc.;
Participation in Corporate programs such as bonus or commission plans wherever appropriate, allowances
and awards, stock programs, etc.;
Inclusion of your work contact details in the worldwide telephone directory and email directory in order to
facilitate internal communications and foster global teamwork;
Enablement of you and your family to participate easily in the various benefit programs - using
information such as family members to be covered by insurance, beneficiaries, etc.;
Fulfillment of government reporting requirements - using information such as tax information and other
statutory information;
Fulfillment of corporate and statutory audits conducted by our third party auditors;
Generation of internal reports for headcounts, budgets, workforce planning, training, etc.;
Management of the relocation process – using demographic and legally required information, including
basic information on your family members relocating with you;
Participation in Intel’s Community website to keep informed of marketing opportunities, newsletters,
Rev 7, 2014
events, special programs, and the ability to communicate with other Intel community members;
17) Inclusion in specific bench marketing and survey activities related to employee productivity and efficiency
in order to increase Intel performance as a company; or
18) For the purpose of Open Door investigations should Intel have “probable cause” to search your email and
laptop due to suspected violations of company policies, including Intel guidelines such as the Electronic
Communications Guidelines, and/or criminal or illegal activities.
Intel may also review and disclose your personal information in order to protect Intel and its employees and assets,
including to: (1) safeguard the legal rights, privacy, and safety of Intel or its employees, partners, or contractors; (2)
protect the safety and security of visitors to Intel’s web sites or other properties; (3) investigate and protect against
violations of Intel’s policies, fraud, or other illegal activity or for risk management purposes; (4) respond to inquiries
or requests from law enforcement and other public authorities/government agents; (5) permit Intel to pursue
available legal remedies or limit the damages that we may sustain; (6) enforce our Terms of Service; or (7) comply
with the law or legal process, including data loss prevention laws.
Individuals with access rights to your personal information, including third party vendors (as applicable), have
been educated on data privacy laws and the use of personal information, and have signed Confidential NonDisclosure Agreements holding them accountable for compliance. Locally, the HR Manager has responsibility
for ensuring the protection of all personal information. On a corporate level, the Global Privacy Office has
overall responsibility for data protection compliance.
For a copy of Intel’s data privacy principles and/or privacy policies or if you have any privacy-related questions
please refer to www.intel.com/privacy.
Please select one of the boxes below:
I hereby grant my authorization to Intel for the purposes stated above
I do not grant my authorization to Intel for the purposes stated above. I understand I must
contact my Intel recruiter immediately.
_____________________________
Signature
_____________________________
Print Name
_____________________________
Date
Rev 7, 2014

New Employee Paperwork Summary

Transcription

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