Qme Form 106 - Request For Qme Panel Under Labor Code Form Page 2
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4Claim Number:
Employer and Claims Administrator Information
Employer:
Claims Administrator Company Name:
Claims Adjustor Name:
Street Address or P.O. Box:
City:
State:
Zip Code:
Phone Number:
Defendant's Attorney
First Name
Last Name
Law Firm Name
Address/PO Box (Please leave blank spaces between numbers, names or words)
City
State
Zip Code
Phone Number
Date:
Print Name of Requestor
Signature of Requestor
Note: The party submitting this form must attach a copy of the written objection to an opinion of a treating
physician identifying an issue in dispute.
The completed form must be mailed to:
Division of Workers' Compensation-Medical Unit
P .O. Box 71010, Oakland, CA 94612
(510) 286-3700 or (800) 794-6900
Page 2 of 4
QME Form 106 (rev. 9/15)
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Parent category: Legal