Fill and Sign the 10160 Summary Rating Determinations Comprehensive Form

State of California Division of Workers' Compensation Disability Evaluation Unit REQUEST FOR SUMMARY RATING DETERMINATION of Qualified Medical Evaluator’s Report DEU Use Only INSTRUCTIONS TO THE CLAIMS ADMINISTRATOR: 1. Use this form if employee is unrepresented and has not filed an appli\ cation for adjudication. 2. Complete this form and forward it along with a complete copy of all m\ edical reports and medical records concerning this case to the physician scheduled to evaluate the existence and e\ xtent of permanent impairment or disability. 3. Send the EMPLOYEE'S DISABILITY QUESTIONNAIRE, DEU FORM 100 to the emp\ loyee in time for the medical evaluation. 4. This form must be served on the employee prior to the evaluation. Be \ sure to complete the proof of service. INSTRUCTIONS TO THE PHYSICIAN: 1. If the employee is unrepresented, review and comment upon the Employe\ e's Disability Questionnaire, (DEU Form 100), in your report. (If the employee does not have a completed Fo\ rm 100 at the time of the appointment, please provide the form to the employee.) 2. Submit your completed medical evaluation and, if the employee is unre\ presented, the DEU Form 100, to the Disability Evaluation Unit district office listed below. PLEASE USE THIS FORM AS A COVER SHEET FOR SUBMISSION TO THE DISABILITY EVALUATION UNIT. 3. Serve a copy of your report and the Form 100 upon the claims administ\ rator and the employee. DWC-AD form101 (DEU) Page 1 (REV. 11/2008) MM/DD/YYYY MM/DD/YYYY MM/DD/YYYY DEU101 Date of first medical report indicating the existence of permanent impai\ rment or disability: Last date for which temporary disability indemnity was paid: Exam Date Physician Submit To: Disability Evaluation Unit Zip Code CA City Address/PO Box (Please leave blank spaces between numbers, names or wor\ ds) Claims AdministratorEmployee DEU101 Claim Number 1 Claim Number 5 Claim Number 4 Claim Number 3 Claim Number 2 Phone No. Employer Adjustor International Address (Please leave blank spaces between numbers, names\ or words) Street Address 2/PO Box (Please leave blank spaces between numbers, nam\ es or words) Street Address 1/PO Box (Please leave blank spaces between numbers, nam\ es or words) Last Name First Name Zip Code State City Street Address1/PO Box (Please leave blank spaces between numbers, name\ s or words) Company Name Street Address2/PO Box (Please leave blank spaces between numbers, name\ s or words) MI DWC-AD form101 (DEU) Page 2 (REV. 11/2008) (Attach a wage statement/DLSR 5020 if earnings are less than maximum. I\ nclude the value of additional advantages provided such as meals, lodging, etc. If earnings are irregular or for l\ ess than 30 hours per week, include a detailed description of all earnings of the employee from all sources, including \ other employers, for one year prior to the date of injury. Benefits will be calculated at MAXIMUM RATE unless a complete\ and detailed statement of earnings is attached.) (Please attach job description or job analysis, if available) DWC-AD form101 (DEU) Page 3 (REV. 11/2008) MM/DD/YYYY MM/DD/YYYY DEU101 City Zip Code SSN (Numbers Only) Date of Injury Date of Birth WEEKLY GROSS EARNINGS Case No (if any) OCCUPATION State DWC-AD form101 (DEU) Page 4 (REV. 11/2008) PROOF OF SERVICE BY MAIL On , I served a copy of this Request for Summary Rating Determination on Name of Employee Address CityStateZip by placing 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 fo\ regoing is true and correct. DEU101 Signature