SAVE
SAN FRANCISCO OFFICE
STATE BUILDING ANNEX 395 OYSTER PT. BLVD MAILING ADDRESS: OFFICE OF BENEFIT DETERMINATION
PRINT CLEAR
LOS ANGELES OFFICE
STATE OF CALIFORNIA
DEPARTMENT OF INDUSTRIAL RELATIONS
LOS ANGELES STATE OFFICE BUILDING 107 SOUTH BROADWAY LOS ANGELES, CA 90012-4578
P. O. BOX 603 SAN FRANCISCO, CA 94101-0603
DIVISION OF WORKERS' COMPENSATION
REQUEST FOR INFORMAL RATING By Insurance Carrier or Self-Insurer
To: From:
Office of Benefit Determination Division of Workers' Compensation Address:
Date: Carrier's Claim No.:
Employer: Employee: Social Security Number: Date of Injury: Month, Day and Year of Birth: Age at Injury: Occupation:
(IF OCCUPATION IS NOT CLEARLY DEFINED, ATTACH JOB DESCRIPTION.)
Address:
Wage or Earning Capacity: $ (Including additional advantages) Compensation Rate: For temporary: For permanent:
Per week/month:
(IF LESS THAN MAXIMUM FOR TEMPORARY OR PERMANENT, ATTACH COMPLETE AND DETAILED STATEMENT OF EARNING CAPACITY.)
$ $ ( IF DIFFERENT FROM DOCTOR'S RELEASE DATE OR DATE SHOWN ON DIA FORM 200, PLEASE EXPLAIN)
Last date for which temporary compensation was paid:
If rehabilitation under L.C. 139.5 is involved: (a) Is employee presently receiving rehabilitation benefits, including vocational rehabilitation temporary disability? (b) If vocational rehabilitation services are concluded, last date for which temporary disability was paid was . We attach our complete medical file.
By Telephone No. (213.0666 )
FORM DWC 201 (REV. 8/90)