This is a generic notice that could be used as a guide in preparing a notice of an injury due to the negligence of a third party or a co-employee.
Title: Philadelphia, Pennsylvania — Letter From Employee Notifying Employer of Personal Injury Due to Negligence Introduction: Philadelphia, Pennsylvania, is a thriving city known for its rich history, vibrant culture, and iconic landmarks. This letter aims to inform employers about personal injuries suffered by employees due to negligence and the necessary steps and responsibilities that should be undertaken. The context may vary, but this notification is crucial to protect employees' rights and seek proper assistance in such unfortunate situations. Sample Content: [Your Name] [Your Address] [City, State, ZIP Code] [Email Address] [Phone Number] [Date] [Employer's Name] [Company Name] [Company Address] [City, State, ZIP Code] Dear [Employer's Name], Re: Notification of Personal Injury Sustained at Work due to Negligence I hope this letter finds you in good health and high spirits. I am writing to bring to your attention an unfortunate incident that occurred at the workplace, resulting in personal injury due to negligence. It is my sincere hope that this matter can be addressed promptly and appropriately to ensure the safety and wellbeing of all employees. On [date], I was performing my assigned duties as a valued employee at [company name] when the incident took place. As per section [X] of the Occupational Health and Safety Act, I would like to formally notify you that I sustained a personal injury caused by the negligent actions of another employee/staff, breaching the duty of care owed by the responsible party. [Provide a detailed description of the incident. Include the location, time, and any witnesses present, if applicable. Mention the nature and extent of the injury(s) sustained, as diagnosed by a medical professional. Highlight the evidence supporting your claim that the injury resulted from the negligence of the responsible party.] Due to the aforementioned incident, I have sought medical attention and attached the pertinent medical reports confirming the extent and severity of my injuries. I have also informed the attending physician that this workplace accident was a result of negligence to ensure an accurate documentation of the incident in medical records. My primary goals in notifying you of this personal injury are: 1. To ensure my immediate safety and access to proper medical care. 2. To document and report the incident as required by law. 3. To request an investigation aimed at preventing similar incidents in the future. 4. To avail necessary support, including appropriate leave and financial compensation, as deemed appropriate under local laws and company policies. I kindly request that you take the following actions in response to this notification: 1. Initiate an internal investigation regarding this incident. 2. Provide necessary support, including worker's compensation claims or other applicable benefits, to aid in my recovery. 3. Communicate updates to me promptly regarding the investigation progress, your findings, and any subsequent steps to be taken. I am eager to cooperate fully with any investigative efforts to establish a detailed account of the incident to the best of my ability. Please be aware that I will act diligently to protect my rights and seek appropriate redress in light of this matter, with or without your cooperation. I trust that you understand the gravity of this personal injury notification and will handle it with the attention and urgency it deserves. Together, we can ensure a safe work environment for all employees. I eagerly await your prompt response and appreciate your cooperation to resolve this matter amicably. Thank you for your understanding. Yours sincerely, [Your Name] Enclosures: 1. Medical Reports 2. Witness Statements, if available.Title: Philadelphia, Pennsylvania — Letter From Employee Notifying Employer of Personal Injury Due to Negligence Introduction: Philadelphia, Pennsylvania, is a thriving city known for its rich history, vibrant culture, and iconic landmarks. This letter aims to inform employers about personal injuries suffered by employees due to negligence and the necessary steps and responsibilities that should be undertaken. The context may vary, but this notification is crucial to protect employees' rights and seek proper assistance in such unfortunate situations. Sample Content: [Your Name] [Your Address] [City, State, ZIP Code] [Email Address] [Phone Number] [Date] [Employer's Name] [Company Name] [Company Address] [City, State, ZIP Code] Dear [Employer's Name], Re: Notification of Personal Injury Sustained at Work due to Negligence I hope this letter finds you in good health and high spirits. I am writing to bring to your attention an unfortunate incident that occurred at the workplace, resulting in personal injury due to negligence. It is my sincere hope that this matter can be addressed promptly and appropriately to ensure the safety and wellbeing of all employees. On [date], I was performing my assigned duties as a valued employee at [company name] when the incident took place. As per section [X] of the Occupational Health and Safety Act, I would like to formally notify you that I sustained a personal injury caused by the negligent actions of another employee/staff, breaching the duty of care owed by the responsible party. [Provide a detailed description of the incident. Include the location, time, and any witnesses present, if applicable. Mention the nature and extent of the injury(s) sustained, as diagnosed by a medical professional. Highlight the evidence supporting your claim that the injury resulted from the negligence of the responsible party.] Due to the aforementioned incident, I have sought medical attention and attached the pertinent medical reports confirming the extent and severity of my injuries. I have also informed the attending physician that this workplace accident was a result of negligence to ensure an accurate documentation of the incident in medical records. My primary goals in notifying you of this personal injury are: 1. To ensure my immediate safety and access to proper medical care. 2. To document and report the incident as required by law. 3. To request an investigation aimed at preventing similar incidents in the future. 4. To avail necessary support, including appropriate leave and financial compensation, as deemed appropriate under local laws and company policies. I kindly request that you take the following actions in response to this notification: 1. Initiate an internal investigation regarding this incident. 2. Provide necessary support, including worker's compensation claims or other applicable benefits, to aid in my recovery. 3. Communicate updates to me promptly regarding the investigation progress, your findings, and any subsequent steps to be taken. I am eager to cooperate fully with any investigative efforts to establish a detailed account of the incident to the best of my ability. Please be aware that I will act diligently to protect my rights and seek appropriate redress in light of this matter, with or without your cooperation. I trust that you understand the gravity of this personal injury notification and will handle it with the attention and urgency it deserves. Together, we can ensure a safe work environment for all employees. I eagerly await your prompt response and appreciate your cooperation to resolve this matter amicably. Thank you for your understanding. Yours sincerely, [Your Name] Enclosures: 1. Medical Reports 2. Witness Statements, if available.
Para su conveniencia, debajo del texto en español le brindamos la versión completa de este formulario en inglés. For your convenience, the complete English version of this form is attached below the Spanish version.
