STATE OF CALIFORNIA DEPARTMENT OF INDUSTRIAL RELATIONS DIVISION OF INDUSTRIAL ACCIDENTS - WORKERS' COMPENSATION APPEALS BOARD DISABILITY EVALUATION BUREAU REQUEST FOR INFORMAL RATING OF PRE-APPLICATION CASES (Print or Type Names and Addresses) Date Name of Injured Worker Insurance Carrier/Adjusting Agency Address Address Social Security Number Employer Date of Claimed Injury Address Date of Birth Alleged Injury Sustained Occupation Requested by: Petitioner Address worker others employer carrier DIA FORM 400 (REV. 11-78) 2002 © American LegalNet, Inc.