Free Microsoft Word - QME Form 122on112408 clean - California

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State of California DIVISION OF WORKERS' COMPENSATION ­ MEDICAL UNIT AME or QME Declaration of Service of Medical - Legal Report (Lab. Code § 4062.3(i))
Case Name:_________________________________ v _______________________________________________
(employee name) (claims administrator name, or if none employer)

Claim No.:_______________________

EAMS or WCAB Case No. (if any):___________________

I, ____________________________________________________________________________, declare: (Print Name) 1. 2. 3. I am over the age of 18 and not a party to this action. My business address is:_________________________________________________________________ On the date shown below, I served the attached original, or a true and correct copy of the original, comprehensive medical-legal report on each person or firm named below, by placing it in a sealed envelope, addressed to the person or firm named below, and by: A depositing the sealed envelope with the U. S. Postal Service with the postage fully prepaid. placing the sealed envelope for collection and mailing following our ordinary business practices. I am readily familiar with this business's practice for collecting and processing correspondence for mailing. On the same day that correspondence is placed for collection and mailing, it is deposited in the ordinary course of business with the U. S. Postal Service in a sealed envelope with postage fully prepaid. placing the sealed envelope for collection and overnight delivery at an office or a regularly utilized drop box of the overnight delivery carrier. placing the sealed envelope for pick up by a professional messenger service for service. (Messenger must return to you a completed declaration of personal service.) personally delivering the sealed envelope to the person or firm named below at the address shown below. Date Served: Addressee and Address Shown on Envelope:

B

C

D

E

Means of service:
(For each addressee, enter A ­ E as appropriate)

____________________ ____________________ ____________________ ____________________

________ ________ ________ ________

____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________

I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Date: _________________________________________

___________________________________________
(signature of declarant)
QME Form 122 Rev. February 2009

______________________________
(print name)