Form 10133.35 - State Of California Page 3
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4Physical requirements for performing work activities (include modifications to usual and customary job):
PTP
QME
AME
Name of doctor who approved job restrictions (optional):
Date of report:
MM/DD/YYYY
Proof of Service by Mail
(To Be Completed By the Employer or Claims Administrator)
I declare that: On
,
I served the attached on:
by placing a true copy thereof enclosed in a sealed envelope with postage thereon fully paid, in the United States mail.
by personal service.
I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct, and that this
was exectuted on:
at
declaration
, CA.
Signature:
Print Name:
DWC-AD form 10133.35 (SJDB) Eff: 1/1/14 - Page 3 of 4
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