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Petition For Permanent Disability Rating WCAB-41 - California
|Petition For Permanent Disability Rating Form. This is a California form and can be used in General Workers Comp .||
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STATE OF CALIFORNIA DEPARTMENT OF INDUSTRIAL RELATIONS DIVISION OF INDUSTRIAL ACCIDENTS WORKERS' COMPENSATION APPEALS BOARD Case No. Applicant VS. Petition for Permanent Disability Rating Defendants Petitioner hereby represents that the disability for which Application has heretofore been filed has now become permanent: Temporary disability payments have been paid in the total sum of $ covering the period of disability beginning including , , ; , to and and for the period of disability beginning , , , . , , and to and including Petitioner alleges that temporary disability ceased on and that disability became permanent on or about in that regard invites attention to the medical reports hereto attached and which are hereby made a part of this petition. WHEREOF, petitioner requests that permanent disability be rated and that Findings and Award for Permanent Disability issue. Petitioner Address Copies mailed to the following on DATE : Attorney for Petitioner Address of Attorney DIA WCAB FORM 41 (REV. 11-76) 2002 © American LegalNet, Inc.