I am an employee of xxx (employer), and my ID number is xxx.

I was injured at work on X, X, X, and after treatment and medical treatment, I now apply for labor ability appraisal. Please handle it.

Applicant (signature):

Xxx year x month x day

Unit opinion: xxx

Seal of unit:

X year x month x day

Legal basis: Article 8 of the Administrative Measures for Appraisal of Work-related Injury Workers: To apply for appraisal of work ability, an application form for appraisal of work ability shall be filled in and the following materials shall be submitted: (1) The original and photocopy of the decision on appraisal of work-related injury; (2) Complete medical records such as valid diagnosis certificates, copies or duplicates of inspection reports that meet the relevant provisions of medical institution medical record management; (three) the original and photocopy of the valid identity certificate such as the resident ID card or social security card of the injured employee; (four) other materials as prescribed by the labor ability appraisal committee.