TRISTAR COMPLAINT RESOLUTION FORM Injured Worker’s Name: _______________________________ Telephone: ___________________ Injured Worker’s Address: __________________________________________________________ Injured Worker’s Employer: City of Los Angeles Claim #: ____________________ Administrator:
Date of Injury: __________________________
Tristar Integrated Services
Tristar claims examiner: ____________________________________________________________ Workers’ Compensation Appeals Board Case Number (if applicable) ________________________ Describe complaint: (Include date or dates of alleged violations) ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ •
Attach copies of supporting documentation, if available
Documentation is strictly for the purpose of verifying business practices of Tristar. We are not seeking confidential information about your medical condition. Send complaints and attachments to: UFLAC Attn.: Dave Pimentle, Secretary 1571 Beverly Blvd., Suite 201 Los Angeles, CA 90026
