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Legibly Print or Type the information requested in this form. You may fax this request, along with the completed proof of service, to (510) 622-3467.If you need further information, please call us at (510) 286-3700 or 1-800-794-6900. Instant access to fillable Microsoft Word or PDF forms. Minimize the risk of using outdated forms and eliminate rejected fillings. When requesting an extension, Form 112 is to be filed and served on all parties prior to the date the evaluation report is due. A: The extension form is due to the DWC, injured worker, and insurance carrier no later than 5 days before the ordinary filing deadline. Medical Evaluation Time Frames; Extensions for QMEs and AMEs. Frame Extension Request). Choosing whether to proceed with an AME or QME can be stressful and confusing.