Dwc Ad Form 102 PDF Details

In the complex and procedural world of workers' compensation within the State of California, the DWC AD 102 form serves as a crucial document for those navigating the aftermath of workplace injuries occurring on or after January 1, 1994. This form, officially titled "Request for Summary Rating Determination," is intended for submission to the Disability Evaluation Unit (DEU) and plays a pivotal role in the determination of an injured worker's disability rating. As part of the process, it requires comprehensive completion and the inclusion of the primary treating physician's report, ensuring that the evaluation is grounded in medical findings. Furthermore, the form mandates that both the requesting party and the opposing side — typically the employee and claims administrator — receive copies of all submitted documentation, promoting transparency and allowing for the correction of inaccuracies, particularly in the description of the occupation or earnings. The DWC AD 102 form also encompasses sections for detailed personal and employment information, a precise account of the injury, and a declaration of the service method, all underscored by the necessity of a sworn accuracy under penalty of perjury. This document, therefore, not only facilitates a fair assessment of disability claims but also underscores the importance of accuracy, thoroughness, and procedural compliance in the workers' compensation system.

QuestionAnswer
Form NameDwc Ad Form 102
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namesDEU102, foregoing, deu forms, dwc

Form Preview Example

State of California

Division of Workers' Compensation

Disability Evaluation Unit

REQUEST FOR SUMMARY RATING DETERMINATION DEU Use Only of Primary Treating Physician Report

To be used for injuries which occur on or after January 1, 1994.

INSTRUCTIONS :

1.Complete this form and send it to the Disability Evaluation Unit along with a copy of the primary treating physician's report.

2.This form and any attachments including a copy of the primary treating physician's report must be served on the other party .

3.If you receive the completed form from the other party and you disagree with the description of the occupation or earnings, please attach the correct information to a copy of this form and send it to the Disability Evaluation Unit. You must also send a copy of your objection to the other party.

REQUEST IS MADE BY:

PHYSICIAN

Employee

Claims Administrator

EXAM DATE

MM/DD/YYYY

Claims Administrator Information (if known and if applicable)

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

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)

City

 

State

 

Zip Code

Claim No.

Phone Number

Adjustor

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DWC-AD form102 (DEU) (11/2008)

DEU102

 

 

 

 

 
WEEKLY GROSS EARNINGS: $

Employee

Mr.

Ms.

Mrs.

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)

City

 

State

 

Zip Code

Date of Injury

MM/DD/YYYY

Date of Birth

MM/DD/YYYY

SSN (Numbers Only)

Case No.

Employer

Nature of Employers Business

Job Title

DESCRIBE THE GENERAL DUTIES OF THE JOB (Attach job description or job analysis, if available):

. 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 received.

DWC-AD form102 (DEU) (11/2008)

DEU102

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 Code

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 form102 (DEU) (11/2008)

DEU102

 

How to Edit Dwc Ad Form 102 Online for Free

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Step 2: The tool lets you modify your PDF form in a range of ways. Change it with customized text, correct what is already in the file, and add a signature - all at your convenience!

To be able to finalize this PDF form, ensure that you enter the necessary details in each and every field:

1. First, when completing the deu rating request form, start out with the area with the next blank fields:

Part number 1 in filling in YYYY

2. When the last part is complete, you're ready to insert the essential details in Claim No, Phone Number, Adjustor, DWCAD form DEU, and DEU so that you can move forward to the next step.

Step number 2 in filling out YYYY

3. In this particular part, check out Employee, Mrs, First Name, Last Name, Street Address PO Box Please leave, Street Address PO Box Please leave, International Address Please leave, State, Zip Code, City, Date of Injury, Date of Birth, MMDDYYYY, and MMDDYYYY. All these will need to be taken care of with utmost accuracy.

Step # 3 in filling out YYYY

4. This next section requires some additional information. Ensure you complete all the necessary fields - SSN Numbers Only, Case No, Employer, Nature of Employers Business, Job Title, DESCRIBE THE GENERAL DUTIES OF THE, WEEKLY GROSS EARNINGS are less, and Attach a wage statementDLSR if - to proceed further in your process!

WEEKLY GROSS EARNINGS are less, Employer, and Job Title in YYYY

Those who work with this PDF frequently make some errors when filling out WEEKLY GROSS EARNINGS are less in this section. You should definitely go over everything you enter right here.

5. The pdf needs to be completed by filling in this section. Further one can find a comprehensive list of blanks that need to be completed with correct details to allow your form usage to be complete: I served a copy of this Request, PROOF OF SERVICE BY MAIL, Name of Employee, Address, City, State, Zip Code, by placing a true copy enclosed in, and Signature.

Writing section 5 in YYYY

Step 3: Prior to addressing the next step, it's a good idea to ensure that all blanks have been filled in as intended. As soon as you think it is all good, press “Done." Go for a 7-day free trial option with us and obtain immediate access to deu rating request form - download or edit inside your personal account page. At FormsPal.com, we aim to make sure your information is kept protected.

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