State of California Department of Industrial Relations Division of Workers ' Compensation Request fo 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the 'Person Requesting Correction' section. Indicate whether you are the injured worker or a claims administrator, and provide your name and contact information.
3. Enter the 'Employee Date of Birth' and 'Date of Injury' using the MM/DD/YYYY format. Ensure accuracy as these fields are required.
4. In the 'QME, Case and Report Information' section, input the QME's name, address, and panel number. Leave appropriate spaces between numbers and words for clarity.
5. Complete the 'Employee Information' section with the injured worker's details including their first name, last name, and address.
6. Fill in the 'Employer and Claims Administrator Information' with relevant details about the employer and claims administrator.
7. Indicate any factual information you believe is incorrect in the designated field. You may attach additional pages if necessary but refrain from including medical information.
8. Finally, complete the declaration of service section to confirm that all parties have been notified appropriately.

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