Complete this form (print or type the information). Sign and date at bottom.
Specialty: select only ONE specialty.
To determine if the injury is work-related: include a copy of the claims administrator's notice that the claim was denied, or a copy of its request for an evaluation.
Employee mails: the completed signed form and Proof of Service to the Division of Workers' Compensation - Medical Unit.
Employee's copy: mail or deliver a signed copy of the form and Proof of Service to your Claims Administrator.
| Question | Answer |
|---|---|
| Form Name | QME Form 105 |
| Form Length | 3 pages |
| Fillable? | Yes |
| Fillable fields | 46 |
| Avg. time to fill out | 8 min |
| Edition | Rev 09/15 |
| Issuing agency | State of California, Division of Workers' Compensation |
| Matches the agency's file | Yes, checked October 3, 2026 |
| Other names | QME Form 105, QME 105, Form 105, DWC Form 105, QME panel request form, Request for Qualified Medical Evaluator Panel |
| Official source | QME Form 105 (Rev 09/15), Division of Workers' Compensation |
Qme Form 105 isn’t the one you’re looking for?