John Cruz

 
 131 3274625
 Reset Form 
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 STATE OF CALIFORNIA 
 Division of Workers' Compensation 
 Disability Evaluation Unit 
 EMPLOYEE'S DISABILITY QUESTIONNAIRE 
 DEU Use Only 
 This form will aid the doctor in determining your permanent impairment or disability. Please compl猫te this form and 
 give it to the physician who will be performing the evaluation. The doctor will include this form with his or her report 
 and submit it to the Disability Evaluation Unit, with a copy to you and your claims administrator. 
 Employee 
 Florentino 
 First Name 
 MI 
 Mejia 
 Last Name 
 SSN (Numbers Only) 
 1624 Travion Court #1, Fairfield, CA 3274625 
 Street Address 1/PO Box (Please leave blank spaces between numbers, names or words) 
 International Address (Please leave blank spaces between numbers, names or words) 
 Fairfield 
 CA 
 94533 
 City 
 State 
 Zip Code 
 Date of Birth 
 21 August 2003
 MM/DD/YYYY 
 Date of Injury 
 09 October 2019
 MM/DD/YYYY 
 Chevy's 
 Employer 
 Restaurant 
 Nature of Employers Business 
 Claim Number 1 
 0024060013b6wc01 
 DWC-AD form100 (DEU) Page 1 (REV. 11/20328) 
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