Get Deu 101

The Deu 101 form is essential for requesting a summary rating determination from a qualified medical evaluator. This guide provides clear instructions on completing the form online, ensuring a smooth submission process.

Follow the steps to successfully fill out the Deu 101 form.

1. Click ‘Get Form’ button to access the Deu 101 and open it in your preferred online editing tool.
2. Enter the date of the first medical report indicating the existence of permanent impairment or disability in the specified MM/DD/YYYY format.
3. Provide the last date for which temporary disability indemnity was paid, using the MM/DD/YYYY format.
4. Fill in the address details for submission, ensuring all blank spaces are appropriately managed. Include street addresses, city, state, and zip code.
5. Complete the physician details section, including the name of the physician and the examination date in the MM/DD/YYYY format.
6. Input all relevant claim numbers in the designated fields. If there are multiple claims, ensure each number is entered clearly.
7. Fill in the employee’s personal information, including their first name, middle initial, last name, address, date of injury, date of birth in MM/DD/YYYY format, and social security number.
8. Detail the employee's occupation and attach any job description or analysis if available. Include weekly gross earnings with any additional benefits, following the guidelines provided.
9. Complete the proof of service by mail section, including the date of service, name of the employee, and their mailing address. Ensure you sign this section appropriately.
10. After confirming all information is accurate and complete, proceed to save changes. You may download, print, or share the completed form as needed.

Complete your Deu 101 form online today to ensure timely processing of your request.