Request For Summary Rating Determination Or Primary Treating Physician Report {DWC-AD 102 (DEU)}

DWC-AD form102 (DEU), REQUEST FOR SUMMARY RATING DETERMINATION of Primary Treating Physician Report, To be used for injuries which occur on or after January 1, 1994. INSTRUCTIONS: 1. Complete this form and send it to the Disability Evaluation Unit along with a copy of the primary treating physician's report. 2. This form and any attachments including a copy of the primary treating physician's report must be served on the other party. 3. If you receive the completed form from the other party and you disagree with the description of the occupation or earnings, please attach the correct information to a copy of this form and send it to the Disability Evaluation Unit. You must also send a copy of your objection to the other party. (11/2008). www.FormsWorkflow.com