LC 2810.5 Notice (Revised 11 2014)-2026

1. Click ‘Get Form’ to open the LC 2810.5 Notice in our editor.
2. Begin by entering the employee's name and start date in the designated fields under 'EMPLOYEE'.
3. Fill in the hiring employer's legal name and indicate if they are a staffing agency by checking 'Yes' or 'No'.
4. Provide any other names the hiring employer operates under, along with their physical and mailing addresses.
5. Input the hiring employer’s telephone number for contact purposes.
6. If applicable, complete the section regarding the entity for whom the employee will perform work, including their contact details.
7. Detail wage information by specifying rates of pay and checking appropriate boxes for overtime rates.
8. Indicate whether a written agreement exists regarding pay rates and provide allowances claimed as part of minimum wage.
9. Complete the worker’s compensation section with insurance carrier details and policy number.
10. Select the appropriate option regarding paid sick leave entitlements based on your situation.
11. Finally, ensure both employer and employee sign and date the acknowledgment of receipt section at the bottom of the form.

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