Free DWC -AD Form 102 DEU - California

State of California Division of Workers' Compensation Disability Evaluation Unit REQUEST FOR SUMMARY RATING DETERMINATION of Primary Treating Physician Report
To be used for injuries which occur on or after January 1, 1994.

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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.

REQUEST IS MADE BY: PHYSICIAN EXAM DATE

Employee

Claims Administrator

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

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 Date of Injury Date of Birth

State

Zip Code

MM/DD/YYYY

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 On Name of Employee Address City State Zip Code , I served a copy of this Request for Summary Rating Determination on

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 form102 (DEU) (11/2008)

DEU102