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Employees Request For Informal Permanent Disability Rating DIA-200 - California
|Employees Request For Informal Permanent Disability Rating Form. This is a California form and can be used in General Workers Comp .||
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SAN FRANCISCO OFFICE 525 GOLDEN GATE AVENUE SAN FRANCISCO PLEASE SEND TWO COPIES MAIL ADDRESS: P.O. BOX 603 SAN FRANCISCO 94101-0603 STATE OF CALIFORNIA Department of Industrial Relations Division of Industrial Accidents DISABILITY EVALUATION BUREAU LOS ANGELES OFFICE LOS ANGELES STATE OFFICE BUILDING 107 SOUTH BROADWAY LOS ANGELES 90012-4578 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) Nature of employer's business (City) (Zip Code) 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? Sign here DIA FORM 200 (REV. 2-86) Date 86 39691 DIA-200 2002 © American LegalNet, Inc.