Request For Informal Rating By Insurance Carrier Or Self-Insurer
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Request For Informal Rating By Insurance Carrier Or Self-Insurer Form. This is a California form and can be use in General Workers Comp.
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Tags: Request For Informal Rating By Insurance Carrier Or Self-Insurer, DIA-201, California Workers Comp, General
SAN FRANCISCO OFFICE
LOS ANGELES OFFICE
STATE BUILDING ANNEX
LOS ANGELES STATE OFFICE BUILDING
STATE OF CALIFORNIA
395 OYSTER PT. BLVD
MAILING ADDRESS:
OFFICE OF BENEFIT DETERMINATION
P.O. BOX 603
SAN FRANCISCO, CA 94101-0603
107 SOUTH BROADWAY
LOS ANGELES, CA 90012-4578
DEPARTMENT OF INDUSTRIAL RELATIONS
DIVISION OF WORKERS' COMPENSATION
REQUEST FOR INFORMAL RATING
By Insurance Carrier or Self-Insurer
To: Office of Benefit Determination
Division of Workers' Compensation
Date:
From:
Address:
Carrier's Claim No.:
Employer:
Employee:
Address:
Social Security Number:
Date of Injury:
Month, Day and Year of Birth:
Age at Injury:
Occupation: (IF OCCUPATION IS NOT CLEARLY DEFINED, ATTACH JOB DESCRIPTION.)
Wage or Earning Capacity: $
Per week/month:
(Including additional advantages) (IF LESS THAN MAXIMUM FOR TEMPORARY OR PERMANENT, ATTACH
COMPLETE AND DETAILED STATEMENT OF EARNING CAPACITY.)
Compensation Rate:
For temporary:
$
For permanent:
$
Last date for which temporary compensation was paid:
(IF DIFFERENT FROM DOCTOR'S
RELEASE DATE OR DATE
SHOWN ON DIA FORM 200,
PLEASE EXPLAIN)
If rehabilitation under L.C. 139.5 is involved:
(a) Is employee presently receiving rehabilitation benefits, including vocational rehabilitation temporary disability?
(b) If vocational rehabilitation services are concluded, last date for which
temporary disability was paid was
.
We attach our complete medical file.
By
Telephone No. (
FORM DWC 201 (REV. 8/90)
)
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