Request For Summary Rating Determination Page 4
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4PROOF 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
DEU101
DWC-AD form101 (DEU) Page 4 (REV. 11/2008)
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