Voluntary Abandonment Of Claim {WC191}

COLORADO DEPARTMENT OF LABOR & EMPLOYMENT Division of Workers' Compensation 633 17th Street, Suite 400 Denver, CO 80202 Voluntary Abandonment of Claim Claimant Name: Date of Injury: Insurance Carrier: Workers' Compensation No. Carrier Claim No. Employer: I am voluntarily abandoning all future entitlements to the above captioned workers' compensation claim by completing this form. I understand that by completing this form I am waiving any future benefits to which I may be entitled, including : Payment for time lost from work, and; Payment for any permanent impairment, and; Payment for disfigurement. I understand that by completing this form I am waiving entitlement to any current and future medical benefits, including reimbursement of mileage to and from related medical treatment. I understand that I may request that this claim be reopened, but only within a limited time, and only for limited reasons, including a change in medical condition. If the insurance company or the employer objects to my request to reopen, the issue will be decided by a judge at a hearing. I understand that a Final Admission of Liability will be filed and my claim will be closed if I do not object to the Final Admission of Liability. I have not been offered anything of value in exchange for waiving these rights and for completing this form. Signature of Claimant Print Name I, , , Date (print name of interpreter) I read this document in its entirety to the For use by a language interpreter, if necessary: affirm that on this day of individual whose name appears above in that person's native language, and that the person indicated an understanding of each and every provision contained on this form. (Signature) For use by insurer: I certify and affirm that neither I nor those I am acting for have offered anything of value in exchange for the claimant's abandonment of this claim. Signature of Claims Representative Print Name Date WC191 Rev 03/14 American LegalNet, Inc. www.FormsWorkFlow.com