Request For Qualified Medical Evaluator Panel Page 2
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3PROOF OF SERVICE
Instructions:
1.Complete the Proof of Service.
2. For Employee: Mail the completed signed form and Proof of Service to:
Division of Workers’ Compensation – Medical Unit
P.O. Box 71010, Oakland, CA 94612
(510) 286-3700 or (800) 794-6900
3. For Employee: Mail or deliver a signed copy of the form and Proof of Service to your Claims Administrator.
4. For Claims Administrator/Defense Attorney: Mail the completed signed form attach a copy of the written
objection to an opinion of a treating physician, and Proof of Service, to the Medical Unit with a copy served to
the Employee.
I declare that I am a resident of or employed in the county of __________________, California; I am over the
age of eighteen years.
On ________________, I served the attached completed Form 105 on the following parties:
by mail to:
______________________________________
Name of Employee or Claims Administrator
______________________________________
Street Address
_______________________________________
City, State, Zip code
by hand-delivery to:
______________________________________
Name
______________________________________
Street Address
_______________________________________
City, State, Zip code
I declare, under penalty of perjury under the laws of the State of California, that the foregoing is true
and correct.
Executed on _____________________, at _______________________, California
Type or Print Name:__________________________________________
Signature:__________________________________________________
QME Form 105 (rev. 09/15)
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