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Request For Informal Rating By Insurance Carrier Or Self-Insurer DIA-201 - California
|Request For Informal Rating By Insurance Carrier Or Self-Insurer Form. This is a California form and can be used in General Workers Comp .||
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SAN FRANCISCO OFFICE STATE BUILDING ANNEX 395 OYSTER PT. BLVD MAILING ADDRESS: OFFICE OF BENEFIT DETERMINATION P.O. BOX 603 SAN FRANCISCO, CA 94101-0603 LOS ANGELES OFFICE STATE OF CALIFORNIA LOS ANGELES STATE OFFICE BUILDING 107 SOUTH BROADWAY LOS ANGELES, CA 90012-4578 DEPARTMENT OF INDUSTRIAL RELATIONS DIVISION OF WORKERS' COMPENSATION REQUEST FOR INFORMAL RATING By Insurance Carrier or Self-Insurer To: Office of Benefit Determination Division of Workers' Compensation From: 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: $ Per week/month: (Including additional advantages) (IF LESS THAN MAXIMUM FOR TEMPORARY OR PERMANENT, ATTACH COMPLETE AND DETAILED STATEMENT OF EARNING CAPACITY.) Compensation Rate: For temporary: $ For permanent: $ Last date for which temporary compensation was paid: (IF DIFFERENT FROM DOCTOR'S RELEASE DATE OR DATE SHOWN ON DIA FORM 200, PLEASE EXPLAIN) 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. ( FORM DWC 201 (REV. 8/90) . ) 2002 © American LegalNet, Inc.