California Workers Compensation Questionnaire

State:
Multi-State
Control #:
US-Q1038
Format:
Word; 
Rich Text
Instant download

Description

This form addresses important matters that may effect the legal rights and obligations of the parties in a workers' compensation matter. This questionnaire enables those seeking legal help to effectively identify and prepare their issues and problems. Thorough advance preparation enhances the attorney’s case evaluation and can significantly reduce costs associated with case preparation.



This questionnaire may also be used by an attorney as an important information gathering and issue identification tool when forming an attorney-client relationship with a new client. This form helps ensure thorough case preparation and effective evaluation of a new client’s needs. It may be used by an attorney or new client to save on attorney fees related to initial interviews.


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FAQ

Time: You have three hours to complete the exam. Please arrive 30 minutes prior to your scheduled appointment time to complete the necessary sign-in process.

Either the DEU, QME, or AME will review your case, including all medical records, and determine your disability rating based the factors discussed above. You have a right to receive a copy of the disability rating report and challenge its findings if you disagree with them.

The job of the QME is to examine you, evaluate you, and write a thorough medical report about your case. These reports define the injured worker's eligibility for Workers' Comp benefits. QMEs include osteopathy doctors, chiropractic doctors, dentists, optometrists, podiatrists, psychologists, and acupuncturists.

Certificate of Workers' Compensation Insurance The certificate must be written by an insurance company licensed through the California Department of Insurance. CSLB must be listed as the Certificate Holder. The contractor's business name and license number must be listed. The policy number must be listed.

They will examine you and all your medical records to determine the extent of your work-related injury. They will decide if you have any permanent disability and what future medical care you may need. It is important that the doctor has all your medical records.

Qualified medical evaluators (QMEs) are qualified physicians who are certified by the Division of Workers' Compensation - Medical Unit to examine injured workers to evaluate disability and write medical-legal reports. The reports are used to determine an injured worker's eligibility for workers' compensation benefits.

If you have an attorney, the QME will send a copy of the report to your lawyer and the claims administrator. From here, a disability rater from the DWC Disability Evaluation Unit will issue you a disability rating within 20 days, after which you and your attorney can begin discussing settlement of your case.

The QME report is used to determine a disability rating. The rating will range from 0% disability (no functional impairment) up to 100% disability (permanently and totally disabled).

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California Workers Compensation Questionnaire