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SAN FRANCISCO OFFICE
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Department of Industrial Relations Division of Industrial Accidents DISABILITY EVALUATION BUREAU
STATE O F CALIFORNIA
L O S ANGELES OFFICE
LOS ANGELES STATE OFFICE B U I L D I N G 107 SOUTH BROADWAY LOS ANGELES 90012
EMPLOYEE'S REQUEST FOR INFORMAL PERMANENT DISABILITY RATING This form should be completed and submitted as soon as the permanent effects of the injury appear stationary.
IMPORTANT--This is not a request for a Hearing or an Award. This will not prevent the operation of the Statute of Limitations. EMPLOYEE
(Please Print)
EMPLOYER Address
(Zip Code)
Social Security No. Address
(Street and Number, or Rural Route) (City) (Zip Code)
Nature of employer's business
Date of injury
(Month) (Day) (Year)
Age (give date of birth)
(Month) (Day) (Year)
Employer's Workers' Compensation Insurance Carrier:
Occupation (at time of injury) Have you returned to work? Date If so, when ?
Have you ever sustained any other permanent disability? What was its nature?
PLEASE ANSWER FOLLOWING QUESTIONS FULLY, using reverse side if needed. What were the general duties of your job when you were injured?
What is your disability resulting from this injury?
How does this disability affect you in your work?
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D I A F O R M 200 (REV. 8-79)
Date