New Employee Paperwork Summary - Intel · New Employee Paperwork Summary ... TO EMPLOYMENT...

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 DATE Rev. 11/2010

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.

http://www.intel.com/lifeatintel/values/

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 EMPLOYEE SIGNATURE WORLDWIDE ID DATE

Intel updated Rev 11/2014

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 Please provide the following information regarding your employment with the temporary agency or service agency. Incomplete forms will not be processed.

Agency Name: _____________________________________________________ (example: Kelly Services)






____________________________________________________________________________________



____________________________________________________________________________________

Additional Prior Service Credit Eligibility Information Please provide the following information regarding your employment with the temporary agency or service agency. Incomplete forms will not be processed. Agency Name: _____________________________________________________ (example: Kelly Services)






____________________________________________________________________________________



____________________________________________________________________________________

Intel Confidential rev. 1/1/2014

Intel Confidential NEONHBensigform12/4/2013

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 STD plan as supplement coverage at a combined state STD Plan and Intel STD Plan cost of 0.9% of wages to an annual 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 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 $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.

http://www.intel.com/go/myben

http://www.intel.com/go/myben

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.

© Sedgwick CMS 2013 MH SB863 Page 1

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 Santa Clara - Mission

FM2 – 1st Floor In the link between SC9 and SC12

Mon – Fri 8 a.m. – 5 p.m. Mon – Fri 8 a.m. – 5 p.m.

Phone: 916-356-5039 Phone: 408-765-9587

Fax: 916-356-6960 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 2006 Page 2

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:

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 work-related 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 work- related 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.

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. Your employer must offer group health coverage 2. Your personal physician must agree in advance to

treat you for any work injuries or illnesses 3. Your physician must be your regular physician and

surgeon. 4. 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

http://www.harborsys.com/sedgwick2


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 Network Employee Notification.

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.

Emergency Medical Care:

If you need emergency care, call 911 for help immediately from the hospital, ambulance, fire department or police department.

First Aid:

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.

Temporary Disability (TD) Benefits:

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.

Permanent Disability (PD) Benefits:

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:

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 education-related 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.

Return to Work Fund

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.

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.

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

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.

https://www.caworkcompcoverage.com/

http://www.dir.ca.gov/

© Sedgwick CMS 2013 MH SB863Page 5

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, obstetrician-

gynecologist, 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).

© Sedgwick CMS 2013 MH SB863 Página 6

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 2010 Página 7

NNoottiiffiiccaacciióónn ddee nnuueevvaa ccoonnttrraattaacciióónn ––

LLeessiioonneess ooccaassiioonnaaddaass eenn eell ttrraabbaajjoo

¿¿QQuuéé ccuubbrree llaa iinnddeemmnniizzaacciióónn ppoorr aacccciiddeenntteess

llaabboorraalleess??

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.

BBeenneeffiicciiooss::

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.

AAtteenncciióónn mmééddiiccaa::

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.

SSuu MMééddiiccoo PPrriimmaarriioo ddee TTrraattaammiieennttoo ((PPTTPP))::

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,

los quiroprácticos no pueden seguir siendo médicos primarios

de tratamiento. Si en su caso son necesarios especialistas, 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.

TTrraattaammiieennttoo ppoorr ppaarrttee ddee ssuu mmééddiiccoo ppaarrttiiccuullaarr::

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:

1. Su empleador debe ofrecer seguro médico colectivo.

2. Su médico particular debe estar de acuerdo previamente en darle tratamiento por lesiones o enfermedades laborales.

3. Su médico debe ser su médico de cabecera y cirujano.

4. Su médico previamente se ha encargado de su tratamiento y conserva sus registros, inclusive su historial médico.

¿¿QQuuéé ssuucceeddee ssii ssuu eemmpplleeaaddoorr ccuueessttiioonnaa llaa lleessiióónn??

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.

RReeddeess ddee PPrroovveeeeddoorreess ddee AAtteenncciióónn MMééddiiccaa::

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


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:

NNúúmmeerroo tteelleeffóónniiccoo ggrraattuuiittoo ddee llaa RReedd ddee

PPrroovveeeeddoorreess ddee AAtteenncciióónn MMééddiiccaa aaccttuuaall:: 880000--662255--

66558888

SSiittiioo wweebb ddee llaa MMPPNN::

wwwwww..hhaarrbboorrssyyss..ccoomm//sseeddggwwiicckk22

1. Ir a www.harborsys.com/sedgwick2 2. Ingrese la información de ubicación o información

específica del proveedor en la "Búsqueda de Proveedores" caja

3. Seleccione las disciplinas apropiadas médicos del "Filtro por especialidad" menú desplegable

4. Haga clic en el azul "Buscar" cuando esté listo

DDiirreecccciióónn ddee llaa RReedd ddee PPrroovveeeeddoorreess ddee AAtteenncciióónn

MMééddiiccaa aaccttuuaall::

Sedgwick CMS 10690 White Rock Road Suite 100 Rancho Cordova, CA 95670 Fecha en que entra en vigor la MPN: 4/15/2014

¿¿YY ssii mmii eemmpplleeaaddoorr ccuueennttaa ccoonn uunnaa RReedd ddee

PPrroovveeeeddoorreess ddee AAtteenncciióónn MMééddiiccaa??

Consulte la Notificación para los Empleados sobre la Red de Proveedores de Atención Médica que se anexa.

¿¿YY ssii mmii eemmpplleeaaddoorr nnoo ccuueennttaa ccoonn uunnaa RReedd ddee

PPrroovveeeeddoorreess ddee AAtteenncciióónn MMééddiiccaa??

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.

AAtteenncciióónn mmééddiiccaa ddee eemmeerrggeenncciiaa::

Si necesita atención médica de emergencia, llame inmediatamente al 911 para recibir ayuda del hospital, ambulancia, departamento de bomberos o de la policía.

PPrriimmeerrooss aauuxxiilliiooss::

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.

BBeenneeffiicciiooss ppoorr ddiissccaappaacciiddaadd tteemmppoorraall ((TTDD))::

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.

BBeenneeffiicciiooss ppoorr ddiissccaappaacciiddaadd ppeerrmmaanneennttee ((PPDD))::

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

http://www.harborsys.com/sedgwick2


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.

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.

BBeenneeffiicciiooss ppoorr mmuueerrttee::

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.

NNoottiiffiiqquuee ssuu lleessiióónn..

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.

DDiissccrriimmiinnaacciióónn::

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.

¿¿PPrreegguunnttaass??

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.

AAddmmiinniissttrraaddoorr ddee RReeccllaammaacciioonneess::

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.

https://www.caworkcompcoverage.com/

http://www.dir.ca.gov/


RReeccllaammaacciioonneess ffaallssaass yy nneeggaattiivvaass ffaallssaass..

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

encarcelada. 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.


DDEESSIIGGNNAACCIIÓÓNN PPRREEVVIIAA DDEE UUNN MMÉÉDDIICCOO PPAARRTTIICCUULLAARR

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.

NNOOTTIIFFIICCAACCIIÓÓNN DDEE DDEESSIIGGNNAACCIIÓÓNN PPRREEVVIIAA DDEE MMÉÉDDIICCOO PPAARRTTIICCUULLAARR

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)


EEmmpplleeaaddoo MMPPNN AApplliiccaacciióónn ddee nnoottiiffiiccaacciióónn

“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 92806-2141 (714) 414-1801

Oakland 1515 Clay Street, 6th floor Oakland, CA 94612-1519 (510) 622-2861

San Diego 7575 Metropolitan Drive, Suite 202 San Diego, CA 92108-4424 (619) 767-2082

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

San Francisco 455 Golden Gate Avenue, 2nd floor San Francisco, CA 94102-7014 (415) 703-5020

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

San Jose 100 Paseo de San Antonio, Room 241 San Jose, CA 95113-1402 (408) 277-1292

Fresno 2550 Mariposa Mall, Room 2035 Fresno, CA 93721-2219 (559) 445-5355

Redding 2115 Civic Center Drive Room 15 Redding, CA 96001-2740 (530) 225-2047

San Luis Obispo 4740 Allene Way, Suite 100 San Luis Obispo, CA 93401-8736 (805) 596-4159

Goleta 6755 Hollister Avenue, Room 100 Goleta, CA 93117-5551 (805) 968-4158

Riverside 3737 Main Street, Room 300 Riverside, CA 92501-3337 (951) 782-4347

Santa Ana 605 W Santa Ana Blvd, Bldg 28 Room 451 Santa Ana, CA 92701-4070 (714) 558-4597

Long Beach 300 Oceangate Street, Suite 200 Long Beach, CA 90802-4304 (562) 590-5240

Sacramento 160 Promenade Circle, Suite 300 Sacramento, CA 95834-2962 (916) 928-3158

Santa Rosa 50 "D" Street, Room 420 Santa Rosa, CA 95404-4771 (707) 576-2452

Los Angeles 320 W. 4th Street, 9th floor Los Angeles, CA 90013-1954 (213) 576-7389

Salinas 1880 North Main Street, Suite 100 Salinas, CA 93906-2037 (831) 443-3058

Stockton 31 East Channel Street, Room 344 Stockton, CA 95202-2314 (209) 948-7980

Marina del Rey 4720 Lincoln Blvd 2nd floor Marina del Rey, CA 90292-6902 (310) 482-3820

San Bernardino 464 W. Fourth Street, Suite 239 San Bernardino, CA 92401-1411 (909) 383-4522

Van Nuys 6150 Van Nuys Blvd., Room 105 Van Nuys, CA 91401-3370 (818) 901-5367

http://www.dir.ca.gov/dwc/DWC_address/Anaheim.html

http://www.dir.ca.gov/dwc/DWC_address/Oakland.html

http://www.dir.ca.gov/dwc/DWC_address/SanDiego.html

http://www.dir.ca.gov/dwc/DWC_address/Bakersfield.html

http://www.dir.ca.gov/dwc/DWC_address/Oxnard.html

http://www.dir.ca.gov/dwc/DWC_address/SanFrancisco.html

http://www.dir.ca.gov/dwc/DWC_address/Eureka.html

http://www.dir.ca.gov/dwc/DWC_address/Pomona.html

http://www.dir.ca.gov/dwc/DWC_address/SanJose.html

http://www.dir.ca.gov/dwc/DWC_address/Fresno.html

http://www.dir.ca.gov/dwc/DWC_address/Redding.html

http://www.dir.ca.gov/dwc/DWC_address/SanLuisObispo.html

http://www.dir.ca.gov/dwc/DWC_address/Goleta.html

http://www.dir.ca.gov/dwc/DWC_address/Riverside.html

http://www.dir.ca.gov/dwc/DWC_address/SantaAna.html

http://www.dir.ca.gov/dwc/DWC_address/LongBeach.html

http://www.dir.ca.gov/dwc/DWC_address/sacramento.html

http://www.dir.ca.gov/dwc/DWC_address/SantaRosa.html

http://www.dir.ca.gov/dwc/DWC_address/LosAngeles.html

http://www.dir.ca.gov/dwc/DWC_address/Salinas.html

http://www.dir.ca.gov/dwc/DWC_address/Stockton.html

http://www.dir.ca.gov/dwc/DWC_address/MarinaDelRey.html

http://www.dir.ca.gov/dwc/DWC_address/SanBernardino.html

http://www.dir.ca.gov/dwc/DWC_address/VanNuys.html

Rev 7, 2014

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) 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;

2) Training and career development – information pertaining to education, skills, certifications, training

requirements, training history, course completed/needed, performance evaluations/reviews;

3) 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;

4) Management of IT and Facilities Services to include office, telephone, email, and computer equipment,

services and access rights;

5) Payroll processing - using information such as your salary, bank account details, total deductions,

allowances, etc.;

6) 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.;

7) Support for your technical resource needs, including support of your computer and communications

hardware and software, through Intel’s Technical Assistance Center.

8) 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.;

9) Participation in Corporate programs such as bonus or commission plans wherever appropriate, allowances

and awards, stock programs, etc.;

10) Inclusion of your work contact details in the worldwide telephone directory and email directory in order to

facilitate internal communications and foster global teamwork;

11) 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.;

12) Fulfillment of government reporting requirements - using information such as tax information and other

statutory information;

13) Fulfillment of corporate and statutory audits conducted by our third party auditors;

14) Generation of internal reports for headcounts, budgets, workforce planning, training, etc.;

15) Management of the relocation process – using demographic and legally required information, including

basic information on your family members relocating with you;

16) 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 Non-

Disclosure 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

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