Date Employee Address City, State, Zip Date of Injury Claim Number Claims Administrator Address City, State, Zip Telephone Number Employer NOTICE REGARDING PERMANENT DISABILITY BENEFITS (Claims Administrator's name) is handling your workers' compensation claim on behalf of (Employer). This notice is to advise you of the status of permanent disability payments for your workers' compensation injury of . Only the items completed below concern your benefits at this time. Payments for permanent disability are the period from The first payment is beginning through being resumed continuing for . enclosed sent separately. $ based on your earnings of $ will be sent to you every two weeks on $ has been paid based on These payments will be deducted from any award you may receive. Your weekly compensation rate is per week. Payments and will continue until . The report from your treating physician, Dr. , dated , states that your injury became permanent and stationary on . The report also indicates that your injury has resulted in permanent disability of %. This rating is equivalent to $ , which is paid at a rate of $ weeks, per week for beginning . The report also indicates that you are are not in need of continuing medical care. You and I both have the right to disagree with the treating physician's findings and request a comprehensive medical evaluation from a panel of Qualified Medical Evaluators supplied by the Industrial Medical Council. I accept the findings described in the report. However, I am enclosing the form required by the Industrial Medical Council, which you may use to request assignment of a panel if you disagree with the findings. Optional: If on the other hand you agree with the findings, please complete and return the enclosed stipulations to me, and I will initiate the process to obtain a Permanent Disability Award. I disagree with the findings described in the report. I have enclosed the form required by the Industrial Medical Council, which you must use to request assignment of a panel by the Industrial Medical Council. I have requested a rating of the report from the State Disability Evaluation Unit, and you will receive a copy of that rating when it is completed. I have not requested a rating of the report from the State Disability Evaluation Unit. However, you may contact an Information and Assistance Officer to have the report rated by the Disability Evaluation Unit if you wish. Since you are represented by an attorney, you may obtain an additional medical evaluation from an Agreed Medical Evaluator if both the parties agree. If no agreement on an Agreed Medical Evaluator can be reached, you may obtain an additional medical evaluation from a Qualified Medical Evaluator of your choice. Contact your attorney to discuss arrangements for the evaluation. 3/96 DWC 500-B 2002 © American LegalNet, Inc. The report from your treating physician, Dr. , dated , states that your injury became permanent and stationary on . The extent of your permanent disability and whether or not you need continuing medical care must be determined by a Qualified Medical Evaluator. I have enclosed the form required by the Industrial Medical Council, which you must use to request assignment of a panel of Qualified Medical Evaluators. You have the responsibility to select a physician from the panel and set up an examination. Please notify me when you have made your appointment. It is too soon to tell if you will have any permanent disability from your injury. I will be checking with your doctor until your condition is permanent and stationary. At that time your doctor will determine whether or not you have any permanent disability and/or need for further medical care. I expect to have this information by and I will notify you of the status of permanent disability at that time. Payments are ending because Benefits paid to you total $ through for the period from per week. . at $ Included in this amount is Permanent disability vocational rehabilitation supplement totalling $ Permanent disability lump sum(s) totalling $ Overpayment totalling $ . . . We will assert credit for the overpayment against . Additionally, you have received 10% self-imposed increases totalling $ If you disagree with this decision and if you are represented by an attorney, please call your attorney. Otherwise, if you have questions, please call me at . The State of California requires this notice to include the following language: If you want further information, you may contact the local State Information and Assistance Office by calling (enter district I&A office telephone number closest to the injured worker) or you may receive recorded information by calling 1-800-736-7401. You may also consult an attorney of your choice. Should you decide to be represented by an attorney, you may or may not receive a larger award, but, unless you are determined to be ineligible for an award, the attorney's fee will be deducted from any award you might receive for disability benefits. The decision to be represented by an attorney is yours to make, but it is voluntary and may not be necessary for you to receive your benefits. With or without an attorney, you may ask to have your case heard by the Workers' Compensation Appeals Board. Sincerely, , Claims Examiner Enc.: cc: DWC 500-B PD Fact Sheet Payment Record Applicant's Attorney QME Selection Form Employee Claim Form 3/96 2002 © American LegalNet, Inc.