QME Form 105 - State of California - dir ca 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the 'Date of Injury' in MM/DD/YYYY format. This is a required field.
3. Input the 'Claim Number' assigned by your claims administrator, which is also required.
4. Select the 'Requesting party' by checking the appropriate box: Injured Employee, Defense Attorney, or Claims Administrator.
5. Specify the 'Specialty Requested' using the three-letter code from the attached list.
6. Indicate the reason for requesting a QME panel by checking one of the boxes related to Labor Code sections 4060, 4061, or 4062.
7. Fill out the 'Employee Information' section with personal details such as name and address. If applicable, provide information about previous QME panels.
8. Complete the 'Employer and Claims Administrator Information' section with relevant details about your employer and claims administrator.
9. If applicable, include information about any defense attorney involved in your case.
10. Finally, date and sign the form where indicated before submitting it to ensure all required fields are completed.

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