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Request For Reconsideration Of Summary Rating By The Administrative Director Form. This is a California form and can be use in EDD Forms Workers Comp.
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Tags: Request For Reconsideration Of Summary Rating By The Administrative Director, DEU-103, California Workers Comp, EDD Forms
REQUEST FOR RECONSIDERATION OF SUMMARY RATING
BY THE ADMINISTRATIVE DIRECTOR
This form may be used by an unrepresented employee or his or her employer to request that the Administrative
Director determine whether a permanent disability rating issued by the Disability Evaluation Unit should be
reconsidered pursuant to Labor Code Section 4061(k).
A request for reconsideration may be granted if it is shown that the Qualified Medical Evaluator (QME) or Treating
Physician (TP) has failed to address all issues, failed to completely address issues, failed to follow the procedures
promulgated by the Industrial Medical Council (IMC), or if the rating was incorrectly calculated. This procedure is
applicable only to injuries occurring on or after 1/1/91. Please verify that you sent a copy of this request to the other
party (employee or claims administrator) by filling out the proof of service below after reading the instructions on the
reverse side.
This request must be submitted within thirty (30) days of receipt of the rating.
SEND TO: Administrative Director
Division of Workers' Compensation
Attn: Summary Rating Reconsideration
P.O. Box 420603
San Francisco, CA 94142
INCLUDE: (1) This completed form;
(2)
(3)
(4)
A copy of the Summary Rating;
A copy of the Qualified Medical
Evaluation (QME) or Treating Physician
(TP) report;
Other information supporting the
request.
Disability Evaluation
Unit File Number:
Employer/Insurer
Claim Number:
Employee's
Social Security Number:
Employee Name:
Employee Address:
Employer/Adjusting
Agency:
Employer/Adjusting
Agency Address:
Date of Injury:
REASON(S) FOR REQUEST:
(Check reason and explain below. Attach additional sheets if necessary.)
QME/TP failed to address all issues
QME/TP failed to completely address issues
IMC procedures not followed by QME/TP
Rating was incorrectly calculated
Explanation:
Reconsideration of Summary Rating is being requested by:
.
(Injured worker/Employer/Claims Adjusting Agency)
PROOF OF SERVICE BY MAIL
On
(Instructions on Reverse)
I served a copy of this Request for Reconsideration of Summary Rating on
(date)
at
(name of employee or claims administrator)
by placing
(address)
a true copy enclosed in a sealed envelope with postage fully prepaid, and deposited in the U.S. Mail. I declare under
penalty of perjury under the laws of the State of California that the foregoing is true and correct.
Signature
DEU Form 103 (Rev. 06/02)
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www.USCourtForms.com
INSTRUCTIONS FOR COMPLETING THE PROOF OF SERVICE BY MAIL
Complete the Proof of Service By Mail on the reverse side as follows:
PROOF OF SERVICE BY MAIL
On
#1
(SAMPLE)
I served a copy of this Request for Reconsideration of Summary Rating on
(date)
#2
at
(name of employee or claims administrator)
#3
by placing
(address)
a true copy enclosed in a sealed envelope with postage fully prepaid, and deposited in the U.S. Mail.
I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
Signature
#4
1)
List on line #1 the date on which you mailed this form.
2)
If you are the Injured Employee, list on line #2 the name of the Insurance Carrier or Claims Adjusting Agency
handling your case. If you are the Insurance Carrier/Claims Adjusting Agency, list the name of the Injured
Employee.
3)
List on line #3 the mailing address for the Insurance Carrier/Claims Adjusting Agency or Injured
Employee you listed on line #2.
4)
Sign your name on line #4.
DEU Form 103 (Rev. 06/02)
American LegalNet, Inc.
www.USCourtForms.com
