Employees Request For Informal Permanent Disability Rating
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Employees Request For Informal Permanent Disability Rating Form. This is a California form and can be use in General Workers Comp.
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Tags: Employees Request For Informal Permanent Disability Rating, DIA-200, California Workers Comp, General
PLEASE SEND TWO COPIES
SAN FRANCISCO OFFICE
STATE OF CALIFORNIA
Department of Industrial Relations
Division of Industrial Accidents
525 GOLDEN GATE AVENUE
SAN FRANCISCO
MAIL ADDRESS: P.O. BOX 603
SAN FRANCISCO 94101-0603
LOS ANGELES OFFICE
LOS ANGELES STATE OFFICE BUILDING
107 SOUTH BROADWAY
LOS ANGELES 90012-4578
DISABILITY EVALUATION BUREAU
EMPLOYEE'S REQUEST FOR INFORMAL PERMANENT DISABILITY RATING
This form should be completed and submitted as soon as the permanent effects of the injury appear stationary.
IMPORTANT
This is not a request for a Hearing or an Award. This will not prevent the operation of the Statute of
Limitations.
EMPLOYEE
EMPLOYER
(Please Print)
Social Security No.
Address
Address
Nature of employer's business
(Zip Code)
(Street and Number, or Rural Route)
(City)
(Zip Code)
Date of injury
(Month)
(Day)
(Year)
(Month)
(Day)
(Year)
Age (give date of birth)
Employer's Workers' Compensation Insurance Carrier:
Occupation (at time of injury)
Have you returned to work?
Date
Have you ever sustained any other permanent disability?
If so, when?
What was its nature?
PLEASE ANSWER FOLLOWING QUESTIONS FULLY, using reverse side if needed.
What were the general duties of your job when you were injured?
What is your disability resulting from this injury?
How does this disability affect you in your work?
Sign here
DIA FORM 200 (REV. 2-86)
Date
86 39691
DIA-200
2002 © American LegalNet, Inc.
