Dwc Ad Form 101 PDF Details

Managing workers' compensation claims in the state of California involves a detailed process, especially when addressing the extent of an employee's permanent impairments or disabilities following a workplace injury. The DWC AD 101 form, issued by the Division of Workers' Compensation Disability Evaluation Unit, plays a critical role in this process for unrepresented employees who have not initiated an adjudication application. This form facilitates the request for a summary rating determination based on a Qualified Medical Evaluator's report. It requires meticulous completion by claims administrators who need to forward all relevant medical reports and records for the case, alongside ensuring the employee prepares by providing them with the EMPLOYEE'S DISABILITY QUESTIONNAIRE, DEU FORM 100, before their medical evaluation. Further instructions guide the evaluating physician on how to handle the form and subsequent medical evaluation, underpinning the importance of a transparent and informed process for determining compensation for workplace injuries. This form acts as a conduit for ensuring all parties, including the employee, claims administrator, and physician, align in their understanding and documentation of the injury and its impacts.

QuestionAnswer
Form NameDwc Ad Form 101
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namesDEU101 california request for deu rating form

Form Preview Example

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 application for adjudication.

2.Complete this form and forward it along with a complete copy of all medical reports and medical records concerning this case to the physician scheduled to evaluate the existence and extent of permanent impairment or disability.

3.Send the EMPLOYEE'S DISABILITY QUESTIONNAIRE, DEU FORM 100 to the employee 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 Employee's Disability Questionnaire, (DEU Form 100), in your report. (If the employee does not have a completed Form 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 unrepresented, 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 administrator and the employee.

Date of first medical report indicating the existence of permanent impairment or disability:

MM/DD/YYYY

Last date for which temporary disability indemnity was paid:

MM/DD/YYYY

Submit To: Disability Evaluation Unit

Address/PO Box (Please leave blank spaces between numbers, names or words)

CA

City

Zip Code

Physician

Exam Date

MM/DD/YYYY

DWC-AD form101 (DEU) Page 1 (REV. 11/2008)

DEU101

Claims Administrator

Company Name

Street Address1/PO Box (Please leave blank spaces between numbers, names or words)

 

Street Address2/PO Box (Please leave blank spaces between numbers, names or words)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

State

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Claim Number 1

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Claim Number 2

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Claim Number 3

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Claim Number 4

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Claim Number 5

 

 

 

 

 

 

 

 

 

Phone No.

 

 

 

 

 

 

 

 

 

 

Adjustor

 

 

 

 

 

 

 

 

 

 

Employer

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employee

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

First Name

MI

 

 

 

 

Last Name

Street Address 1/PO Box (Please leave blank spaces between numbers, names or words)

Street Address 2/PO Box (Please leave blank spaces between numbers, names or words)

International Address (Please leave blank spaces between numbers, names or words)

DWC-AD form101 (DEU) Page 2 (REV. 11/2008)

DEU101

 

 

 

City

 

 

State

 

 

Zip Code

Date of Injury

Date of Birth

 

 

 

MM/DD/YYYY

 

 

 

 

MM/DD/YYYY

SSN (Numbers Only)

Case No (if any)

OCCUPATION

(Please attach job description or job analysis, if available)

WEEKLY GROSS EARNINGS

(Attach a wage statement/DLSR 5020 if earnings are less than maximum. Include the value of additional advantages provided such as meals, lodging, etc. If earnings are irregular or for less 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.)

DWC-AD form101 (DEU) Page 3 (REV. 11/2008)

DEU101

PROOF OF SERVICE BY MAIL

On

 

, I served a copy of this Request for Summary Rating Determination on

Name of Employee

Address

City

 

State

 

Zip

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.

Signature

DWC-AD form101 (DEU) Page 4 (REV. 11/2008)

DEU101

 

 

 

 

 

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This document will require you to provide specific details; in order to guarantee accuracy, be sure to take heed of the tips below:

1. Whenever filling in the Dwc Ad Form 101, make sure to incorporate all necessary fields in its associated section. It will help expedite the work, allowing for your details to be handled efficiently and accurately.

Ways to complete Dwc Ad Form 101 stage 1

2. Right after filling in the last section, head on to the next part and fill out the essential details in these blanks - Claims Administrator, Company Name, Street AddressPO Box Please leave, Street AddressPO Box Please leave, City, Claim Number, State, and Zip Code.

The best way to prepare Dwc Ad Form 101 portion 2

3. Your next stage is straightforward - complete all the form fields in Claim Number, Claim Number, Claim Number, Claim Number, Phone No, Adjustor, Employer, Employee, and First Name to complete this process.

Step # 3 in filling in Dwc Ad Form 101

4. It is time to fill out this fourth section! Here you have these Last Name, Street Address PO Box Please leave, Street Address PO Box Please leave, International Address Please leave, DWCAD form DEU Page REV, and DEU fields to complete.

The best ways to prepare Dwc Ad Form 101 portion 4

5. To wrap up your document, the particular section requires several additional blank fields. Filling in State, Zip Code, Date of Birth, MMDDYYYY, City, Date of Injury, MMDDYYYY, SSN Numbers Only, Case No if any, OCCUPATION Please attach job, WEEKLY GROSS EARNINGS, and Attach a wage statementDLSR if will certainly wrap up everything and you're going to be done in no time!

Part number 5 in completing Dwc Ad Form 101

Always be very mindful when filling out MMDDYYYY and City, since this is the part in which many people make errors.

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