General Admission Of Liability {WC2}

Instructions for Completing the General Admission of Liability Please read all pages This form is "fillable." That means you can type the information onto the form from your computer and print the form. You will not be able to save the form onto your computer's hard drive. When you open the form, click in the "Claimant's Name" box (field), complete the information, and use the tab key to navigate to the next field. Do not use the Enter key; pressing the Enter key will only page down. Each field has been limited. This means that you cannot continue to type information into a field if it doesn't fit into the space provided. Use numbers only to fill in the fields for Social Security #, phone number and dollar amounts. Do not use dashes, parentheses, or dollar signs; when you tab out of the field, it will fill in automatically. If a dollar amount contains cents, do type the period. To fill in a check box, click inside the box with your mouse. To clear or delete all the information you have typed onto the form, click on the red "Clear Entire Form" button. To change the information in one field, use the backspace or delete key. 1 "Clear Entire Form" button Clears all information at once "Check Box" Click in box 2 BENEFITS Compensation benefits are paid by insurance carriers for compensable injuries. Temporary disability benefits are paid every 2 weeks. Temporary Total Disability - Total disability of more than 3 working days. If disability lasts for more than 14 calendar days, compensation shall be paid from the day left work. Compensation is payable at the rate of 66 2/3% average weekly wage in effect at the time the injury/exposure not to exceed the statutory maximum. A loss of fringe benefits specifically enumerated in the statute should be included in the calculation of the average weekly wage. Permanent Partial Disability - Payable where there is residual impairment, based upon the part of the body affected, or on the extent of medical impairment. Facial or Bodily Disfigurement ­ Payable for serious, permanent disfigurement about the head, face, or parts of the body normally exposed to public view. The maximum benefit is established each year for injuries that occur during that year. In addition, for injuries that occurred on or after July 1, 2007, it is possible to receive a larger amount for extensive disfigurement. Information regarding the maximum benefit for your date of injury is located on the Division's website, or you may contact the Customer Service Unit at (303) 318-8700. Medical Benefits - Current medical benefits for medical, hospital and surgical supplies, prescriptions, crutches, apparatus and vocational rehabilitation. Temporary Partial Disability - Temporary partial disability of more than 3 working days. Compensation is payable at the rate of 66 2/3% of the difference between the employee's average weekly wage at the time of injury and said employee's average weekly wage during the continuance of the temporary partial disability not to exceed a maximum of 91% of the state average weekly wage per week. MMI - Maximum Medical Improvement means a point in time where any medically determinable physical or mental impairment as a result of injury has become stable and when no further treatment is reasonably expected to improve the condition. Codes for scheduled ratings: 01 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 Arm @ Shoulder Hand @ Wrist Thumb @Metacarpal Thumb @ Proximal Thumb @ Distal Index @ Metacarpal Index @ Proximal Index @ Second Index @ Distal Middle @ Metacarpal Middle @ Proximal Middle @ Second Middle @ Distal Ring @ Metacarpal Ring @ Proximal Ring @ Second Ring @ Distal Little @ Metacarpal 20 21 22 23 25 26 27 28 29 30 31 32 33 34 35 36 Little @ Proximal Little @ Second Little @ Distal Leg @ Hip Leg @ Foot, Heel, Ankle Great Toe @ Metatarsal Great Toe @ Proximal Great Toe @ Distal Other Toe @ Metatarsal Other Toe @ Proximal Other Toe @ Distal Blindness One Eye Deafness Both Ears Deafness One Ear Total Hearing 2nd Ear WC2 Rev. 0 /1