Fill and Sign the Van Nuys State Office Building Government Building in Van 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 CALIFORNIA Department of Industrial Relations Division of Industrial Accidents DISABILITY EVALUATION BUREAU 525 GOLDEN GATE AVENUE SAN FRANCISCOLOS ANGELES OFFICE LOS ANGELES STATE OFFICE BUILDING 107 SOUTH BROADWAY LOS ANGELES 9001 2 MAIL ADDRESS: P.O. BOX 603 SAN FRANCISCO 94101 EMPLOYEE'S REQUEST FOR INFORMAL PERMANENT DISABILITY RATINGThis 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: DatePLEASE 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 DateDIA FORM 200 (REV. 8-79) Continuation Sheet 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?