Request For Informal Rating Of Pre-Application Cases
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Request For Informal Rating Of Pre-Application Cases Form. This is a California form and can be use in General Workers Comp.
Tags: Request For Informal Rating Of Pre-Application Cases, DIA-400, California Workers Comp, General
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.
