Request For Summary Rating Determination
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State of California
Division of Workers' Compensation
Disability Evaluation Unit
DEU Use Only
REQUEST FOR SUMMARY RATING DETERMINATION
of Qualified Medical Evaluator’s Report
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
320 W Fourth ST. 9th Floor
Address/PO Box (Please leave blank spaces between numbers, names or words)
90013
LOS ANGELES
CA
Zip Code
City
State
HOWARD SOFEN, MD
Physician
Exam Date
MM/DD/YYYY
DEU101
DWC-AD form101 (DEU) Page 1 (REV. 11/2008)
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