Fill and Sign the Co Workers Compensation Form

DIVISION OF WORKERS’ COMPENSATION SETTLEMENT CHECKLIST AND ROUTING SHEET Customer Service 303.318.8700 Claimant’s name: ______________________________________________________________ Social Security Number ____________________________ List all workers’ compensation (WC#) numbers included in this settlement: WC#: _______________________DOI______________ WC#: _______________________DOI______________ WC#: _______________________DOI______________ WC#: _______________________DOI______________ Claimant’s Attorney ________________________________ Reg. # _______________________ Respondent’s Attorney _____________________________ Reg. # _______________________ Other Attorney ____________________________________ Reg. # _______________________ Other Attorney ____________________________________ Reg. # _______________________ Other Attorney ____________________________________ Reg. # _______________________ Type of settlement (check one): □ Full and Final Settlement (F) □ Partial Settlement (P) □ Third Party (Subrogation) Settlement (T) □ Structured Settlement: Limited Period of Time (S) □ Structured Settlement: Lifetime (L) Total amount of settlement award (Include lump sum plus present value of any structured settlement) $_______________________________ Carrier Portion: $__________________________ SIF Portion: $__________________________ Major Med Portion $__________________________ Verify the following by checking the boxes provided: 1. Claimant is represented by an attorney . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . □ 2. Workers’ compensation numbers are correct . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . □ 3. Order and settlement document contain caption with WC number(s), claimant’s name, employer’s name and insurance carrier’s name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . □ 4. Settlement document has original signatures of all parties . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . □ 5. Claimant’s signature on settlement document is notarized . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . □ 6 Waiver of right to reopen is properly conditioned . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . □ 7. Documents include a standard order containing language required by the Division . . . . . . . . . . . . . . . . . . . . . . . . . . .. □ 8. Date claimant signed the settlement document is entered on the order as the date of settlement . . . . . . . . . . . . . . . □ 9. Settlement document provides that the claimant has personally reviewed the stipulation with an attorney and waives the right to a personal appearance before the Director or Administrative Law Judge . . . . . . . . . . . . . . . . . . . . .. . . . . . □ For DOWC use only Y N _____________ Y N _____________ Y N _____________ Y N _____________ Y N _____________ Y N _____________ Y N _____________ Y N _____________ Y N _____________ 10. All hearings before the Office of Administrative Courts and appeals before ICAP, Court of Appeals and Supreme Court have been vacated or dismissed for the workers’ compensation cases listed in this settlement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . □ 11. All mediation, prehearing and settlement conferences before the Division of Workers’ Compensation have been canceled . . . . . . . . . . . . . . . . . □ I certify that I reviewed the attached settlement document and order, and that they contain all of the above information. __________________________________________ _____________ Signature Date ________________________________________________________________ Print Name Representative for: □ Claimant □ Respondent Resubmitted (if initially rejected) ________________________________________________________________ __________________________________________ _____________ Print Name Signature Date Representative for: □ Claimant □ Respondent Instructions for document return: □ Will pick up at Customer Service □ Please mail (Division will mail only if sufficient copies, with addressed, stamped envelopes for all parties are attached) Contact person for information: ________________________________ ____________________________ Name Phone number Contact person for document pickup: ________________________________________ __________________ Name Phone number This form must be completed and submitted with the settlement document and order. Include a mailing certificate if the order is to be mailed. Submit the original settlement document and copies for all parties listed on the mailing certificate. Failure to correctly complete and submit all documents may result in rejection or return of the settlement. Settlement documents for claimants not represented by an attorney must be submitted directly to the Office of Administrative Courts. Do not complete this form if the claimant is unrepresented. Division of Workers’ Compensation Use Only: □ Approved Date: __________________________ By:_________________________________________________________________ □ Rejected (see # ____ above) Date: __________________________ By:_________________________________________________________________ Person picking up documents: _____________________________________________________ _________________________________________________ Print Name Signature On behalf of: ____________________________________________________________________________ Date: ________________________________ Mail or deliver all documents to: Division of Workers’ Compensation, Customer Service 633 17th St., Suite 400, Denver, CO 80202-3660 WC105 Rev 06/05