Fill and Sign the Of Primary Treating Physician Report Form

REQUEST FOR SUMMARY RATING DETERMINATION of Primary Treating Physician Report State of California Division of Workers' Compensation Disability Evaluation Unit DEU Use Only INSTRUCTIONS : 1. Complete this form and send it to the Disability Evaluation Unit alo\ ng with a copy of the primary treating physician's report. 2. This form and any attachments including a copy of the primary treati\ ng physician's report must be served on the other party . 3. If you receive the completed form from the other party and you disag\ ree with the description of the occupation or earnings, please attach the correct information to a copy of this f\ orm and send it to the Disability Evaluation Unit. You must also send a copy of your objection to the ot\ her party. REQUEST IS MADE BY: To be used for injuries which occur on or after January 1, 1994. DWC-AD form102 (DEU) (11/2008) MM/DD/YYYY Claims Administrator Information (if known and if applicable) DEU102 PHYSICIAN EXAM DATE Name (Please leave blank spaces between numbers, names or words) Street Address 1/PO Box (Please leave blank spaces between numbers, nam\ es or words) Street Address 2/PO Box (Please leave blank spaces between numbers, nam\ es or words) City Zip Code Claim No. Phone Number Adjustor Employee Claims Administrator State Employee. Attach a wage statement/DLSR 5020 if earnings are less than maximum. Include the value of additional advantages provid\ ed such as meals, lodging, etc. If earnings are irregular or for less than 30 hours per week, include a detailed descrip\ tion of all earnings of the employee from all sources, including other employers, for one year prior to the date of injury. Ben\ efits will be calculated at MAXIMUM RATE unless a complete and detailed statement of earnings is received. DWC-AD form102 (DEU) (11/2008) MM/DD/YYYY MM/DD/YYYY DEU102 Mr. Ms. Mrs. Last Name First Name MI Street Address 1/PO Box (Please leave blank spaces between numbers, nam\ es or words) City Zip Code SSN (Numbers Only) Job Title Employer Nature of Employers Business DESCRIBE THE GENERAL DUTIES OF THE JOB (Attach job description or job a\ nalysis, if available): WEEKLY GROSS EARNINGS: $ Date of Injury Date of Birth Case No. Street Address 2/PO Box (Please leave blank spaces between numbers, nam\ es or words) International Address (Please leave blank spaces between numbers, names\ or words) State DWC-AD form102 (DEU) (11/2008) PROOF OF SERVICE BY MAIL , I served a copy of this Request for Summary Rating Determination on 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 foregoing is true and correct. DEU102 Name of Employee Address City State Zip Code Signature On