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Get Qme Form 112

Death in evaluator s family. Natural disaster/other community catastrophe interrupted office. Employee s Name Date of Injury Claims Administrator Claim No. Panel No. QME Name CA Lic. No. Date signed QME Signature QME Street Address QME City Telephone Number CA QME State Fax Number FOR DWC USE ONLY Extension approved Medical Director QME Form 112 rev.7/2013 Extension denied and notice mailed to evaluator and parties Date QME Zip Code Declaration .

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