Fillable State of California Division of Workers' Compensation Disability (California)

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State of California Division of Workers' Compensation Disability (California)

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The State of California Division of Workers' Compensation Disability (California) form is 3 pages long and contains:

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State of California
Division of Workers' Compensation
Disability Evaluation Unit
DEU Use Only
REQUEST FOR SUMMARY RATING DETERMINATION
of Primary Treating Physician Report
To be used for injuries which occur on or after January 1, 1994.
INSTRUCTIONS :
1. Complete this form and send it to the Disability Evaluation Unit along with a copy of the primary treating
physician's report.
2. This form and any attachments including a copy of the primary treating physician's report must be served
on the other party .
3. If you receive the completed form from the other party and you disagree with the description of the occupation
or earnings, please attach the correct information to a copy of this form and send it to the Disability
Evaluation Unit. You must also send a copy of your objection to the other party.
Employee Claims Administrator
REQUEST IS MADE BY:
PHYSICIAN
EXAM DATE
MM/DD/YYYY
Claims Administrator Information (if known and if applicable)
Name (Please leave blank spaces between numbers, names or words)
Street Address 1/PO Box (Please leave blank spaces between numbers, names or words)
Street Address 2/PO Box (Please leave blank spaces between numbers, names or words)
City State
Zip Code
Claim No.
Phone Number
Adjustor
DWC-AD form102 (DEU) (11/2008)
DEU102
Reset Form
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Employee
Mr. Ms. Mrs.
First Name
MI
Last Name
Street Address 1/PO Box (Please leave blank spaces between numbers, names or words)
Street Address 2/PO Box (Please leave blank spaces between numbers, names or words)
International Address (Please leave blank spaces between numbers, names or words)
City
State
Zip Code
Date of Injury
MM/DD/YYYY
Date of Birth
MM/DD/YYYY
SSN (Numbers Only)
Case No.
Employer
Nature of Employers Business
Job Title
DESCRIBE THE GENERAL DUTIES OF THE JOB (Attach job description or job analysis, if available):
WEEKLY GROSS EARNINGS: $
. Attach a wage statement/DLSR 5020 if earnings
are less than maximum. Include the value of additional advantages provided such as meals, lodging, etc. If earnings are
irregular or for less than 30 hours per week, include a detailed description of all earnings of the employee from all sources,
including other employers, for one year prior to the date of injury. Benefits will be calculated at MAXIMUM RATE unless a
complete and detailed statement of earnings is received.
DWC-AD form102 (DEU) (11/2008)
DEU102
PROOF OF SERVICE BY MAIL
Name of Employee
Address
On
, I served a copy of this Request for Summary Rating Determination on
City
State
Zip Code
by placing a true copy enclosed in a sealed envelope with postage fully prepaid, and deposited in the U.S. Mail. I declare
under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
Signature
DEU102
DWC-AD form102 (DEU) (11/2008)
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State of California Division of Workers' Compensation Disability (California)

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Completed 10 December 2021

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