Workers Claim For Compensation Transmittal {WC174}

COLORADO DIVISION OF WORKERS COMPENSATION WORKERS CLAIM FOR COMP ENSATION TRANSMITTAL Submitted By: Attorney: ( ) Phone # Mailing Address ( ) Fax # An Entry of Appearance should accompany this form. NAME SS# DOI WC# Division Assigned INSTRUCTIONS The Workers Claim for Compensation Transmittal Form (Transmittal) is used by attorneys at law to submit Workers Claims for Compensation. The Transmittal Form should be accompanied by an Entry of Appearance form. The Transmittal will be returned via fax noting the Workers Compensation number (WC#) assigned by the Division. This WC# must be listed on all future documents relating to the claim. The Transmittal MUST be placed on top of the Entry of Appearance. Attorney: List the name of the attorney submitting the form. Mailing Address: List the mailing address of the attorney submitting the form. Phone #: List the telephone number of the attorney submitting the form . Fax #: List the Fax number of the attorney submitting the form. Name: List the name of the claimant. SS #: List the Social Security Number of the claimant. DOI: List the date of injury. WC#, Division Assigned: Do not complete. The Division will assign the Workers Compensation number. Mail or Deliver to: Division of Workers Compensation 1515 Arapahoe St. Denver, CO 80202-2117 303.318.8700 WC 174 Rev. 02/02