Tip for IME Notice (state-specific)

You MUST attend the IME — failure to attend can result in suspension of benefits

Tip for IME Notice (state-specific)

The IME doctor works for the insurance company, not for you — be factual but do not minimize your symptoms

Tip for IME Notice (state-specific)

You may be entitled to mileage reimbursement and lost wages for attending

Workers' Compensationeasy

Independent Medical Examination Notice

IME Notice (state-specific) · Workers' Comp Insurers

Notice of Independent Medical Examination. Insurer-selected physician evaluates the claimant's condition. Worker must attend or risk benefit suspension.

Form Details

Total fields: 20
Auto-fillable: 15 (75%)
Time without BeneFill: 10 minutes
Time with BeneFill: 3 minutes
Time saved: 7 minutes
Filled by: patient
Frequency: as needed
State-specific: Yes — form may vary by state

Fill this form with BeneFill

Auto-fill 75% of fields from your profile. Save 7 minutes. Download a real PDF.

15 of 20 fields75% auto-filled

Start Filling Upload Your Copy Instead

Where to Submit This Form

📬

The insurance carrier sends this notice to you

This notice is sent BY the carrier TO you. You do not submit it — you receive it.

Filing Deadline

You are typically required to attend the IME. If you cannot attend, notify the carrier immediately to reschedule.

Processing Time

The IME itself usually lasts 30-60 minutes. The physician's report is typically completed within 2-4 weeks.

What Happens Next

The IME physician will submit a report to the insurance carrier. The carrier will use this report to make decisions about your claim, benefits, or treatment.

Tips for This Form

✓ You MUST attend the IME — failure to attend can result in suspension of benefits
✓ The IME doctor works for the insurance company, not for you — be factual but do not minimize your symptoms
✓ You may be entitled to mileage reimbursement and lost wages for attending
✓ Consider bringing a witness or asking if you can record the examination (check your state's rules)

More Workers' Compensation Forms

First Report of Injury (Generic FROI)

FROI · State Workers' Compensation Agencies

Report of workplace injury or occupational disease filed with the state agency and insurer. Required within 3-10 days of injury depending on state. Establishes the claim in the system.

California Workers' Comp Claim Form

DWC-1 · California Division of Workers' Compensation

Employee claim form for workers' compensation benefits in California. Employer must provide within one working day of learning of a workplace injury or illness.

New York Employee Claim

C-3 · New York Workers' Compensation Board

Employee's claim for compensation filed with the NY Workers' Compensation Board. Must be filed within 2 years of the accident or within 2 years of when the claimant knew or should have known the condition was work-related.

Texas Employee's Claim for Compensation

DWC-041 · Texas Department of Insurance, Division of Workers' Compensation

Employee's claim for compensation for a work-related injury or illness in Texas. Must be filed within one year of injury or within one year of when the employee knew or should have known the condition was work-related.

Florida First Report of Injury or Illness

DFS-F2 · Florida Division of Workers' Compensation

Florida's first report of injury or illness form. Employer must file within 7 days of knowledge of an injury or within 24 hours if the injury results in death.

North Carolina Notice of Accident to Employer

Form 18 · North Carolina Industrial Commission

Notice of Accident to Employer and Claim of Employee. Must be filed when injured on the job in North Carolina. Written notice to employer required within 30 days; claim filed within 2 years.

Not sure which forms you need?

Tell our assistant about your situation and we'll find the right forms for you.

Chat with Form Assistant

Disclaimer: BeneFill™ provides form-filling assistance and informational guidance only. It is not affiliated with, endorsed by, or sponsored by the Workers' Comp Insurers or any government agency. The information provided is for general informational purposes and does not constitute legal, medical, financial, or tax advice. Always verify form requirements and submission details directly with the issuing agency.