Application for labor ability appraisal

Applicant: XXX, gender, born on X, X, XX, national, living atNo. XXX, XX Road, XX City, and an employee of XXXXXXX.

Request:

Request for the appraisal of the applicant's disability caused by work-related accidents.

Facts and reasons:

At about XXXX, XX, XX, the applicant was injured by XXXX in the employer XXX, and was recognized as a work-related injury by the XXX Municipal Labor Bureau. The applicant was sent to XXXX hospital for treatment, and the doctor diagnosed it as XXXXXX, etc. He was hospitalized in XXXX Hospital for XX days and discharged on XX, XX, XX. The applicant has lost the ability to work due to physical trauma of XX, and XXXX can't take care of himself, which has caused the applicant's psychological disorder. To this end, I hereby apply for the appraisal of labor ability, requesting the appraisal of the applicant's degree of labor dysfunction and self-care dysfunction, and hope to support it.

This is to

XXXXX Labor Ability Appraisal Committee

Applicant: XXX

XX, XX

If an employee suffers from a work-related injury, and after treatment, the injury is relatively stable and there is disability, which affects his labor ability, he shall be appraised. "Regulations on Industrial Injury Insurance" stipulates that:

Article 21 If an employee suffers from an industrial injury and suffers from disability and affects his/her ability to work after treatment, he/she shall be appraised of his/her ability to work.

Article 22 The appraisal of labor ability refers to the grade appraisal of the degree of labor dysfunction and self-care dysfunction.

Labor dysfunction is divided into ten levels of disability, with the heaviest being level 1 and the lightest being level 1.

There are three levels of self-care disorders: life can't take care of itself at all, most of life can't take care of itself and some of life can't take care of itself.

The labor ability appraisal standard is formulated by the social insurance administrative department of the State Council in conjunction with the health administrative department of the State Council.

article 23 the employer, employees with work-related injuries or their close relatives shall apply to the municipal labor ability appraisal Committee with districts, and provide relevant information on the determination of work-related injuries and medical treatment for employees with work-related injuries.

Reference: Database of laws and regulations-Regulations on industrial injury insurance.