Free DWC - AD Form 103 DEU - California

DIVISION OF WORKERS' COMPENSATION REQUEST FOR RECONSIDERATION OF SUMMARY RATING BY THE ADMINISTRATIVE DIRECTOR

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This form may be used by an unrepresented employee or his or her employer to request that the Administrative Director determine whether a permanent disability rating issued by the Disability Evaluation Unit should be reconsidered pursuant to Labor Code section 4061(g). A request for reconsideration may be granted if it is shown that the Qualified Medical Evaluator (QME) or Primary Treating Physician (PTP) has failed to address all issues, failed to completely address issues, failed to follow the medical evaluation procedures promulgated by the Administrative Director, or if the rating was incorrectly calculated. This procedure is applicable only to injuries occurring on or after 1/1/91. Please verify that you sent a copy of this request to the other party (employee or claims administrator) by filling out the proof of service below after reading the instructions on the reverse side. This request must be submitted within thirty (30) days of receipt of the rating.

SEND TO: Administrative Director

Division of Workers' Compensation Attn: Summary Rating Reconsideration P.O. Box 420603 San Francisco, CA 94142

INCLUDE: (1)This completed form;

(2)Other information supporting the request.

Employee

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 Employer / Adjusting Agency

State

Zip Code

Name (Please leave blank spaces between numbers, names or words) Street Address 1/PO Box (Please leave blank spaces between numbers, names or words)

City
DWC-AD form103 (DEU) Page 1 (Rev. 11/2008)

State

Zip Code DEU103

Disability Evaluation Unit Case Number

Claim Number

SSN (Numbers Only) Date of Injury
MM/DD/YYYY

REASON(S) FOR REQUEST:

(Check reason and explain below. Attach additional sheets if necessary.) QME/PTP failed to completely address issues Rating was incorrectly calculated

QME/PTP failed to address all issues Evaluation procedures not followed by QME/PTP Explanation

Reconsideration of Summary Rating is being requested by: Injured worker Employer/Adjusting Agency

Name PROOF OF SERVICE BY MAIL (Instructions on next page) On , I served a copy of this Request for Reconsideration of Summary Rating on

Address

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
DWC-AD form103 (DEU) Page 2 (Rev. 11/2008)

DEU103

INSTRUCTIONS FOR COMPLETING THE PROOF OF SERVICE BY MAIL
Complete the Proof of Service By Mail PROOF OF SERVICE BY MAIL #1 On I served a copy of this Request for Reconsideration of Summary Rating on
MM/DD/YYYY

(SAMPLE)

#2 (name of employee or claims administrator) #3 Address/PO Box (Please leave blank spaces between numbers, names or words)

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

#4

1) List on line #1 the date on which you mailed this form. 2) If you are the Injured Employee, list on line #2 the name of the Insurance Carrier or Claims Adjusting Agency handling your case. If you are the Insurance Carrier/Claims Adjusting Agency, list the name of the Injured Employee. 3) List on line #3 the mailing address for the Insurance Carrier/Claims Adjusting Agency or Injured Employee you listed on line #2. 4) Sign your name on line #4.

DWC-AD form103 (DEU) Page 3 (Rev. 11/2008)

DEU103