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QME Form 111: QME Findings Summary (Unrepresented)

In California cases where the injured employee has no attorney, Labor Code 4062.3(i) requires the panel QME to summarize the comprehensive medical-legal evaluation on this form. It records event dates, answers on disputed issues such as permanent and stationary status, impairment, causation, apportionment, future care and return to work, and the basis for those conclusions.

Who completes it

The panel QME completes and signs the whole form; the person who serves it signs the built-in declaration of service.

Submitting and payment

How to submit it
Serve it with the report on the employee and claims administrator (or employer) within 30 days from the start of the exam, unless certain conditions are met, and on the DEU when the report finds permanent impairment.
Who pays
The form does not address the evaluation fee.

Good to know

  • Supplying the event dates (appointment call, initial exam, referral for testing and report service) is a legal requirement.
  • If tests or records are pending, check 'Pending or Info. Not Sent', still serve the report within 30 days, and state which issues could not be evaluated.
  • Items 22 to 24 flag disputed issues outside the QME's licensure or competence and the specialty needed; if used, serve a copy on the DWC Medical Unit.
  • Summarize diagnoses in lay terms where possible, except in disputed psyche claims; psyche impairment uses the GAF under the 2005 schedule.

Get the official form

Download the current version from the source each time; forms change without notice.

Qualified Medical Evaluator's Findings Summary Form

Official pagePDF

How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

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Frequently asked questions

When is QME Form 111 used?

Only when the injured employee is unrepresented. The panel QME must summarize the medical findings of the comprehensive medical-legal evaluation on this form, as Labor Code 4062.3(i) requires, and serve it with the report. In represented cases the form is not used.

What is the deadline to serve QME Form 111?

The QME serves the report and this form on the claims administrator (or employer) and the injured worker within 30 days from the start of the examination, unless certain conditions are met. If information is pending, the report should still be served on time, noting the issues not yet evaluated.

Does QME Form 111 go to the Disability Evaluation Unit?

Yes, whenever the report finds permanent impairment and permanent disability. It goes to the DEU office with jurisdiction over the employee's area of residence, and the declaration of service has a line for that service. In unrepresented cases DWC-AD 101 serves as the DEU cover sheet.