New filing — GLF QME Panel Tool

Schedule

Pacific business day for the filing * The executor fires the form at 16:45 PT on the chosen date.

Labor code section *

Requesting party * Who is filing this panel request (required on the DWC form).

Case & dispute

Claim number

ADJ number

Date of injury

Dispute type * Options depend on the labor code section above.

Report date

Objection (30B) mailing date

In-state (CA) defense attorney on the case? Drives the 15-day period (an in-state defense atty = 15 days).

Adjuster (claims admin) out of state? Out-of-state adjuster + no in-state defense = 20-day period.

Waiting period & earliest fire

Enter the objection date to compute.

PTP name (auto-fills physician section)

Scheduled panel-request (fire) date * Defaults to the computed deadline above. Override to lock a specific date — fires at 5:00 PM. Earlier = premature.

Was a written objection communicated within 20 days of your receipt of the report for which objections are being made?

Yes No

If "No," the form requires a good-cause reason for the late objection.

Treating physician & specialties

First name

Last name

Treating specialty

QME specialty requested

Opposing specialty preferred

Injured worker

First

Middle

Last

Street address

City

State

Zip

Applicant attorney

First

Last

Phone

Firm (UAN or name) *

Claims administrator

First

Last

Phone

Employer name

Claims-admin firm (UAN or name)

Defense attorney

First

Last

Phone

Defense firm (UAN or name)

Declaration & confirmation

Requestor first name *

Requestor last name *

I declare under penalty of perjury under the laws of the State of California that I have reviewed the information provided in this eForm and know that the information is true and correct, except as to those matters stated on information and belief, and as to those matters I believe them to be true. By submitting, I agree to serve a copy of the panel request, panel list, and uploaded document on all parties within one business day.

Objection letter (PDF, ≤25 MB)

Drag & drop the objection-letter PDF here, or click to choose.