Fill and Sign the Ca Employee Disability Form

EMPLOYEE      EMPLOYER       Social Security No.       Address       Address                   Date of injury                         Age (give date of birth)                   Occupation (at time of injury)             Have you returned to work?             Have you ever sustained any other permanent disability?       If so, when?       What was its nature?                               PLEASE SEND TWO COPIES SAN FRANCISCO OFFICE STATE OF CALIFORNIADepartment of Industrial RelationsDivision of Industrial Accidents DISABILITY EVALUATION BUREAU 525 GOLDEN GATE AVENUE SAN FRANCISCO LOS ANGELES OFFICE LOS ANGELES STATE OFFICE BUILDING 107 SOUTH BROADWAYLOS ANGELES 9001 2 MAIL ADDRESS: P.O. BOX 603 SAN FRANCISCO 94101EMPLOYEE'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. (Please Print) (Street and Number, or Rural Route) (Street and Number, or Rural Route) (city) (Zip Code) Nature of employer's business (city) (Zip Code) (Month) (Day) (Year) (Month) (Day) (Year) Employer's Workers' Compensation Insurance Carrier: Date 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 Date DIA FORM 200 (REV. 8-79)                   Continuation SheetWhat 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?