Employees Disability Questionnaire {DWC-AD 100 (DEU)}

DWC-AD form100 (DEU), EMPLOYEE'S DISABILITY QUESTIONNAIRE, This form will aid the doctor in determining your permanent impairment or disability. Please complete this form and give it to the physician who will be performing the evaluation. The doctor will include this form with his or her report and submit it to the Disability Evaluation Unit, with a copy to you and your claims administrator. (REV. 11/2008). www.FormsWorkflow.com