Fatal Case-General Admission {WC151}

FATAL CASE - GENERAL ADMISSION Workers Compensation (WC) # ___________________________ Carrier Claim # ___________________________________________ Deceaseds Name ______________________________________ Average Weekly Wage _____________________________________ Deceaseds Social Security # _____________________________ Date of Death _____________________________________________ Date of Injury_________________________________________ Weekly Compensat ion Rate __________________________________ Insurance Ca rrier ______________________________________ Employer ________________________________________________ Third Party Administrato r ________________________________ NOTICE TO CLAIMANT This is an important legal document that can affect your rights. If you disagree with the amount or type of benefits which the carrier has agreed to pay, you may write a letter to the Divisi on of Workers Compensation, 1515 Arapahoe Street, Denver, CO 80202-2117, stating that you object to this ad mission. Please send a copy to the insurance carrier or self-insured employer. See page 2 for other important notices. Liability is admitted for the following benefits: Medical Benefits Safety Rule Violation Funeral Expenses $ ___________________ Offset (Attach Calculation) Complete the following for each known dependent: (Attach additional pages, if needed) Attending School Whole or Partial Name Birth Date Yes or No Relationship Dependency(W or P) If no dependents, has payment been made to the Subsequent Injury Fund (SIF)? Yes No Remarks: (Attach additional pages, if needed) BENEFIT HISTORY - Dependents= benefits (past and present) are admitted for the following: Name Time Periods Weeks Rate per Week Totals __________________________________________ __________through _________ = ______ x $ ____________ = $______________ __________________________________________ __________through _________ = ______ x $ ____________ = $______________ __________________________________________ __________through _________ = ______ x $ ____________ = $______________ __________________________________________ __________through _________ = ______ x $ ____________ = $______________ __________________________________________ __________through _________ = ______ x $ ____________ = $______________ __________________________________________ __________through _________ = ______ x $ ____________ = $______________ The above time periods include the dates specified. Amount of Interest Paid $ ___________________________ Amount ofP enalties Pa id $ __________________________ (Attach additional pages, if needed) Amount Overpaid $ ______________________(See Remarks) Claims Representative ________________________________ Phone# ____________________ Toll-Free Phone # __________________ Address: ________________________________________________________________________________________________________ CERTIFICATE OF MAILING: Copies of this document were placed in the U.S. mail or delivered to the following parties this _________ day of ______________________________, __________. List names and addresses of all persons copied: Name Address Dependent(s): Dependents Attorney(s): Employer: Carriers Attorney: Other: Division of Workers Compensation, 1515 Arapahoe Street, Denver, CO 80202-2117 By: __________________________________________________________________ Block # Adj. Code WC151 Rev 11/98.00 Page 1 of 2 <<<<<<<<<********>>>>>>>>>>>>> 2 (The top portion of this side may be used for mailing address) FATAL CASE - GENERAL ADMISSION IMPORTANT: SEE NOTICE TO CLAIMANT SECTION ON THE OTHER SIDE OF THIS FORM OTHER NOTICES TO CLAIMANT: YOU ARE HEREBY NOTIFIED that the insurance carrier or self-insured employer admits that the fatality reported herein is compensable. YOU ARE ALSO 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 C.R.S. section 8-42-124 and C.R.S. section 26-13-122(4). YOU ARE FURTHER NOTIFIED that you must provide written notice of any award for social security, pension, di sability or other source of income that might reduce your compensation benefits. This notice must be sent to the insurance carrier or self-insured employer within 20 days after learning of the payment or award. Failure to report may r esult in suspension of your benefits pursuant to C.R.S. section 8-42-113.5. WC151 Rev 11/98.00 Page 2 of 2