|
Division
of Workers' Compensation |
|
|
Workers' Compensation Forms
|
|
|
|
What is a
Fillable
form?
|
Commonly Used Terms |
|
|
Form # |
Form Title |
Formats |
| WC1 |
Employer's First Report of Injury |
PDF |
MS Word |
| WC2 |
General Admission of Liability |
PDF |
MS Word |
|
WC3 |
Notice of
One-Time Change of Physician &
Authorization for Release of
Medical Information |
PDF |
MS Word |
|
WC4 |
Final Admission of Liability |
PDF |
MS Word |
|
WC6 |
Entry of Appearance |
PDF |
MS Word |
|
WC12 |
Supplemental Report of Return to
Work |
PDF |
MS Word |
|
WC15 |
Workers' Claim for Compensation |
PDF |
MS Word |
|
WC18 |
Dependent's Notice and Claim for
Compensation |
PDF |
MS Word |
|
WC25 |
Final Payment Notice |
PDF
|
MS Word |
|
WC30 |
Designated
Health Care Provider Disclosure Form |
PDF |
MS Word |
|
WC35 |
Application for Indigent
Determination (Hearing Transcript) |
PDF
|
MS Word |
|
WC35 (IME) |
Application for Indigent
Determination (IME) |
PDF
|
MS Word |
|
WC37 |
Petition to Reopen |
PDF |
MS Word |
|
WC43 |
Rejection of Coverage by Corporate
Officers or Members of a Limited Liability Company |
PDF
|
MS Word |
|
WC44 |
Exclusion of Uncompensated Public
Officials |
PDF
|
MS Word |
|
WC45 |
Rejection of Coverage
By Partners and Sole Proprietors Performing Construction Work on
Construction Sites |
PDF |
MS
Word |
|
WC49 |
Workers Compensation Act Poster |
PDF |
MS Word |
|
WC50 |
Notice to Employer of Injury Poster |
N/A |
MS Word |
|
WC54 |
Petition to Modify, Terminate, or
Suspend Compensation |
PDF
|
MS Word |
|
WC55 |
Objection to Petition to Modify,
Terminate, or Suspend Compensation |
PDF
|
MS Word |
|
WC62 |
Request For
Lump Sum Payment |
PDF
|
MS Word |
|
WC63 |
Request for Offset of Liability to
Subsequent Injury Fund |
PDF
|
MS
Word |
|
WC70 |
Application for Admission to the
Colorado Major Medical Insurance Fund |
PDF
|
MS Word |
|
WC73 |
Settlement Order |
PDF
|
MS Word |
|
WC74 |
Notice of Contest |
PDF |
MS Word |
| WC76 |
Request for Appointment to the
Independent Medical Examination Panel |
PDF |
MS Word |
|
WC77 |
Application for a Division
Independent Medical Examination (IME) |
PDF
|
MS Word |
|
WC98 |
Monthly Summary |
PDF
|
MS Word |
|
WC105 |
Settlement Checklist and Routing
Sheet |
PDF
|
MS Word |
|
WC106 |
First Report Transmittal |
PDF
|
MS Word |
|
WC109 |
Request for Certification |
PDF
|
MS Word |
|
WC112 |
Payroll Statement Form |
PDF
|
MS Word |
|
WC113 |
Surcharge Form |
PDF
|
MS Word |
|
WC131 |
Request for Utilization Review |
PDF
|
MS Word |
|
WC132 |
IME Examiner's Summary Sheet |
PDF
|
MS Word |
|
WC146 |
Notice and Proposal to
Select an
Independent Medical Examiner |
PDF
|
MS Word |
|
WC151 |
Fatal Case - General Admission |
PDF
|
MS Word |
|
WC153 |
Fatal Case - Final Admission |
PDF
|
MS Word |
|
WC164 |
Physician's Report of Workers'
Compensation Injury |
PDF |
MS
Word |
|
WC165 |
Notice of Failed IME Negotiation |
PDF
|
MS Word |
|
WC168 |
Notice of Change of Carrier or
Adjusting Firm |
PDF
|
MS Word |
|
WC169 |
Sender's Transmission Profile |
PDF
|
MS Word |
|
WC170 |
Sender's Trading Partner Profile |
PDF |
MS Word |
|
WC171 |
Third Party Administrator Location
List |
PDF
|
MS Word |
|
WC172 |
Trading Partner Insurer List |
PDF
|
MS Word |
|
WC174 |
Workers' Claim for Compensation
Transmittal |
PDF
|
MS Word |
|
WC175 |
EDI Sender Acceptance Form |
PDF
|
MS Word |
|
WC178 |
Request/Notification
for Follow-up IME |
pdf |
MS Word |
|
WCM3 |
Permanent Work-Related Mental
Impairment Rating Report Worksheet |
PDF
|
MS Word |
|
WCM4 |
Pharmacy Billing Statement |
PDF
|
MS Word |
|
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