Fill and Sign the Ca Workers Compensation Form

                                                                                                                       Last date for which temporary compensation was paid:       tional rehabilitation temporary disability?       temporary disability was paid was       By            SAN FRANCISCO OFFICE STATE BUILDING ANNEX LOS ANGELES OFFICE LOS ANGELES STATE OFFICE BUILDING 395 OYSTER PT. BLVD STATE OF CALIFORNIA DEPARTMENT OF INDUSTRIAL RELATIONS 107 SOUTH BROADWAYLOS ANGELES, CA 90012-4578 MAILING ADDRESS:OFFICE OF BENEFIT DETERMINATIONP. 0. BOX 603 DIVISION OF WORKERS' COMPENSATION SAN FRANCISCO, CA 94101-0603 REQUEST FOR INFORMAL RATING By Insurance Carrier or Self-insurer To: Office of Benefit Determination Division of Workers' Compensation Date: From: Carrier's Claim No.: Address: 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: $ $ (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 voca- (b) If vocational rehabilitation services are concluded, last date for which We attach our complete medical file. Telephone No. FORM DWC 201 (REV. 8/90)