This form is an official California Worker's Compensation form which complies with all applicable state codes and statutes. USLF updates all state forms as is required by state statutes and law. This form is available in fillable PDF format.
A Daly City California Request for Summary Rating Determination for Workers' Compensation is an essential document used in the process of workers' compensation claims in Daly City, California. This request is submitted by an injured employee or their legal representative to the Division of Workers' Compensation (DWC) seeking a determination of their summary rating, which affects their level of compensation. Here is a detailed description of what this request entails, including the different types based on specific circumstances: 1. Purpose: The main purpose of a Daly City California Request for Summary Rating Determination for Workers' Compensation is to identify the appropriate level of compensation for a worker who has experienced a workplace injury or illness in Daly City. 2. Filing the Request: In Daly City, California, the injured worker or their representative should complete the Request for Summary Rating Determination form accurately and submit it to the local DWC office. This form needs to be filed within a specified timeframe, usually within a specified number of days from the date of the injury or knowledge of the injury. 3. Basic Information: The request form requires basic information about the injured worker, such as their name, contact information, Social Security number, and the name of their employer at the time of the injury. It may also ask for details of the injury, including the date and time it occurred and a description of how it happened. 4. Medical Evidence: To support the request, the injured worker may need to attach relevant medical evidence, such as physician reports, diagnostic test results, and any other documentation that helps establish the extent of their injury and the resulting disability. The medical evidence needs to be current and from authorized treating physicians. 5. Wage and Employment Information: The request form may ask for details regarding the injured worker's wages, employment history, and any modifications made to their job duties or working hours following the injury. 6. Specific Circumstances Requests: Depending on the circumstances, there may be different types of Daly City California Requests for Summary Rating Determination, including: a. Permanent Disability (PD) Rating Request: If the worker's injury or illness leads to a permanent disability, they may submit a request for a summary rating determination specifically for PD benefits. b. Vocational Rehabilitation Request: In cases where the injured worker requires vocational rehabilitation due to their workplace injury, a separate request may be filed to assess the need for these services and include them in the determination. c. Supplemental Job Displacement Benefit (JSDB) Request: If the worker is eligible for JSDB benefits (voucher to help with job retraining and skill enhancement), a request can be filed to determine the appropriate amount based on their situation. In summary, a Daly City California Request for Summary Rating Determination for Workers' Compensation is a crucial document used to determine the level of compensation for injured workers in Daly City. Different types of requests may focus on permanent disability, vocational rehabilitation, and supplemental job displacement benefits, each addressing specific circumstances related to the worker's injury.
A Daly City California Request for Summary Rating Determination for Workers' Compensation is an essential document used in the process of workers' compensation claims in Daly City, California. This request is submitted by an injured employee or their legal representative to the Division of Workers' Compensation (DWC) seeking a determination of their summary rating, which affects their level of compensation. Here is a detailed description of what this request entails, including the different types based on specific circumstances: 1. Purpose: The main purpose of a Daly City California Request for Summary Rating Determination for Workers' Compensation is to identify the appropriate level of compensation for a worker who has experienced a workplace injury or illness in Daly City. 2. Filing the Request: In Daly City, California, the injured worker or their representative should complete the Request for Summary Rating Determination form accurately and submit it to the local DWC office. This form needs to be filed within a specified timeframe, usually within a specified number of days from the date of the injury or knowledge of the injury. 3. Basic Information: The request form requires basic information about the injured worker, such as their name, contact information, Social Security number, and the name of their employer at the time of the injury. It may also ask for details of the injury, including the date and time it occurred and a description of how it happened. 4. Medical Evidence: To support the request, the injured worker may need to attach relevant medical evidence, such as physician reports, diagnostic test results, and any other documentation that helps establish the extent of their injury and the resulting disability. The medical evidence needs to be current and from authorized treating physicians. 5. Wage and Employment Information: The request form may ask for details regarding the injured worker's wages, employment history, and any modifications made to their job duties or working hours following the injury. 6. Specific Circumstances Requests: Depending on the circumstances, there may be different types of Daly City California Requests for Summary Rating Determination, including: a. Permanent Disability (PD) Rating Request: If the worker's injury or illness leads to a permanent disability, they may submit a request for a summary rating determination specifically for PD benefits. b. Vocational Rehabilitation Request: In cases where the injured worker requires vocational rehabilitation due to their workplace injury, a separate request may be filed to assess the need for these services and include them in the determination. c. Supplemental Job Displacement Benefit (JSDB) Request: If the worker is eligible for JSDB benefits (voucher to help with job retraining and skill enhancement), a request can be filed to determine the appropriate amount based on their situation. In summary, a Daly City California Request for Summary Rating Determination for Workers' Compensation is a crucial document used to determine the level of compensation for injured workers in Daly City. Different types of requests may focus on permanent disability, vocational rehabilitation, and supplemental job displacement benefits, each addressing specific circumstances related to the worker's injury.