Workers Claim For Compensation {WC15}

Instructions for Completing the Workers' Claim for Compensation 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 "Employee's Name"box (field), 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 Number, phone numbers and dollar amounts. Do not use dashes or parentheses; 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. Some fields contain a drop down menu; click on the arrow and select one of the choices. 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 American LegalNet, Inc. www.USCourtForms.com "Clear Entire Form" button Clears all information at once "Check Box" Click in box "Drop Down Menu" Click on the arrow for choices 2 American LegalNet, Inc. www.USCourtForms.com READ REVERSE SIDE Employee's Name (first, middle, last) Employee's Street Address Age Birthdate Dependents Marital Status COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT Division of Workers' Compensation 633 17th St., Suite 400, Denver, CO 80202-3660 WORKER'S CLAIM FOR COMPENSATION Social Security Number City How Long employed with this employer? Sex State Zip Code Employee's Home Phone Number Occupation Length of experience at this assignment? Print or Use Typewriter Answer Every Question Mail Two Signed Copies DO NOT WRITE IN SHADED AREAS Accident Date Job assigned when injured/exposed? Mo Day Yr Yes No Years of Education Completed (select one) Ethnic Area Employer's Name at Time of Injury or Disease Employer's Mailing Address Address Where Injury or Disease Occurred (street address) Reported to Employer Mo Day Yr Are you receiving pay for Overtime Commissions Piecework Average Weekly Average Weekly Average Weekly Hrs. Per Day Employee's Scheduled Work Week When Injured Employee's Usual Work Schedule $_____________ $_____________ $_____________ Days Per Week To whom was it reported? Employer's Other Company Name SIC City City State State Zip Code County Employer's Phone Number Accident Time Zip Code Sex Service Average Weekly Wage at Time of Injury or Disease $ Check box if you receive Will benefit continue During disability? Hourly Wage at Time of Injury $ Average weekly Value of benefit OCC Source Part of Body Nature Type County AWW Tips Meals $ ____________________ Rooms $ ____________________ Health Insurance * $ ____________________ * If health insurance benefit will not continue during disability, set forth your cost of continuing employer's health insurance or employee's cost of conversion $ _______________ per week. Date of Injury/Disease Injury Time Date Returned to Work ____________________ Disfigurement Scar Date Estimated to Return ____________________ Describe Date Left Work Again ____________________ Date Return to Work Again ____________________ Mo Day Yr Mo Day Yr Injury description (state exactly the part of the body affected, how injury or illness happened, what you were doing at the time, (include name(s) of other individuals involved, tools, machinery, objects, vapors, chemicals, radiations, unnatural motions, etc.). Please specify the items which directly injured you. Last Day Worked Coder 3rd Party Scarring Do you claim to have any permanent disability? Name of Doctor Name of Witness Address Address Name of Hospital Address If claim is for occupational disease (silicosis, asbestosis, anthracosis, radioactivity, or poisoning by uranium, etc.) give dates and names of employers for whom you have worked during the last ten years, and give the name of the employer for whom you last worked and spent a period of 60 days or more breathing or exposed to silicon dioxide, asbestos, or coal dust. (Attach an additional sheet.) _____________ Date _____________________________________________________________ Employer ____________________________________________________________ Address _____________________________________________________________________________ Sign your name FEIN Carrier Claim Number _____________________________ Date Adjuster Code Block Number Policy Number WC15 Rev 05/05.00 American LegalNet, Inc. www.USCourtForms.com GENERAL INFORMATION When your claim forms are received by the Division of Workers' Compensation, a copy will be sent to your employer's worker's compensation insurance carrier for their position. If they fail to admit liability within the prescribed time limit, you will be advised by the Division how to proceed further. REPORTING INJURY Seek medical aid as soon as possible. The employer in the first instance has the right to select a physician to attend the injury. Failure on the part of an injured employee to report and remain under the care of a doctor tendered by an employer or its insurance carrier can result in the injured employee being responsible for unauthorized medical expenses. If services are not tendered at the time of the injury, the employee shall have the right to select his own physician. If an injured employee desires to obtain the services of a physician of his choice, he must first request in writing to his insurance carrier permission to change doctors, and receive written permission from the compensation carrier authorizing a change of physician. If such permission is neither granted nor refused within twenty days, the insurance carrier shall be deemed to have waived any objection. Notify employer of injury. Failure to report injury to employer in writing within 4 days could result in loss of one day's compensation for each day's failure to do so. Failure to attend medical appointments may be reason for the insurance carrier to suspend benefits. BENEFITS YOU ARE HEREBY NOTIFIED that if a child support obligation is owed, compensation benefits may be attached and payment of the child support obligation may be withheld and forwarded to the obligee pursuant to sections 8-42-124 and 2613-122(4), C.R.S. YOU ARE FURTHER NOTIFIED t