Fill and Sign the Colorado Admission Liability Form

COLORADO DEPARTMENT OF LABOR & EMPLOYMENT DIVISION OF WORKERS’ COMPENSATION GENERAL ADMISSION OF LIABILITY WC # Carrier # TO: Soc. Sec. # Claimant’s Name Employer Date of Injury Claimant’s Address Average Weekly Wage Date first payment paid TTD and Date first payment PPD DIVISION OF WORKERS’ COMPENSATION Date of MMI YOU ARE HEREBY NOTIFIED that the insurance carrier or self-insured employer (named below) admits that the injury or occupational disease 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 sections 8-42-124 and 26-13-122(4), C.R.S. YOU ARE FURTHER NOTIFIED that you must provide written notice of any award for social security, pension, disability 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 result in suspension of your benefits pursuant to section 8-42-113.5, C.R.S. Liability is admitted for the following benefits: See Reverse Side for Codes Safety Rule Violation   medical benefits Offset  Attach Calculation  temporary total disability Amount of Interest Paid $  temporary partial disability Amount of Penalties Paid $  rehabilitation maintenance benefits  Working unit % Disability Age  disfigurement 1.  Schedule Injury % (part of body)  permanent partial disability 2.  Schedule Injury % (part of body) Complete the following if admitting for disability Type of Benefit Time Periods Rate per Week Totals thru = wks $ $ thru = wks $ $ thru = wks $ $ thru = wks $ $ thru = wks $ $ thru = wks $ $ thru = wks $ $ The above time periods represent inclusive dates. Remarks: NOTICE TO CLAIMANT: IF YOU DISAGREE WITH THE AMOUNT OR TYPE OF BENEFITS WHICH THE CARRIER HAS AGREED TO PAY, YOU MAY WRITE A LETTER TO THE DIVISION OF WORKERS’ COMPENSATION, 633 17 th ST., SUITE 400, DENVER, CO 80202-3660, STATING THAT YOU OBJECT TO THIS ADMISSION OF LIABILITY. Carrier or Self-Insured Address Telephone No. By: Adjuster or Claims Representative Copies of this admission were mailed this day of , to: WC2 Rev 05/05 PLEASE READ REVERSE SIDE Block # Adj. Code  Claimant’s Attorney  Employer  Division of Workers’ Compensation  Respondent’s Attorney  Claimant 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 - Serious, permanent disfigurement about the head, face or parts of the body normally exposed to public view. Benefits are not to exceed $2000. 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 Arm @ Shoulder 03 Hand @ Wrist 04 Thumb @Metacarpal 05 Thumb @ Proximal 06 Thumb @ Distal 07 Index @ Metacarpal 08 Index @ Proximal 09 Index @ Second 10 Index @ Distal 11 Middle @ Metacarpal 12 Middle @ Proximal 13 Middle @ Second 14 Middle @ Distal 15 Ring @ Metacarpal 16 Ring @ Proximal 17 Ring @ Second 18 Ring @ Distal 19 Little @ Metacarpal 20 Little @ Proximal 21 Little @ Second 22 Little @ Distal 23 Leg @ Hip 25 Leg @ Foot, Heel, Ankle 26 Great Toe @ Metatarsal 27 Great Toe @ Proximal 28 Great Toe @ Distal 29 Other Toe @ Metatarsal 30 Other Toe @ Proximal 31 Other Toe @ Distal 32 Eye Enucleation 33 Blindness One Eye 34 Deafness Both Ears 35 Deafness One Ear 36 Total Hearing 2nd Ear WC2 Rev 05/05 PLEASE READ REVERSE SIDE Block # Adj. Code