Colorado Workers' Claim Form

COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT
DIVISION OF WORKERS’ COMPENSATION
DEPENDENT’S NOTICE AND CLAIM FOR COMPENSATION

See instructions on reverse side before completing form

Employee’s name (first, middle, last) Social Security # Male Female

Employee’s home phone # Division Use Only

Employee’s street address City State Zip code

Birth date Marital status Married Single Separated Unknown Dependents Yes No Date of hire Occupation Employment status Full time Other Part time Unknown

Employer’s name (Company) Employer’s phone # Division Use Only

Employer’s mailing address City State Zip code Coder

Average Weekly Wage

A. Calculate the average weekly wage. Multiply the average number of hours worked per week, excluding overtime, times the hourly wage Subtotal (A) $

B. Check box if employee received Provide the average weekly value of the benefit

Overtime $

Tips (amount reported to IRS) $

Commissions $

Piecework $

Mileage (if a form of salary) $

Other (room, board, etc.) $

Health Insurance (see instructions) $

Subtotal (B) $

C. Add subtotals A & B = Average weekly wage at time of injury (C) $

Date of injury/disease Date of death Time employee began work a.m. p.m.

Injury time a.m. p.m. Unknown Last date worked Date employer notified

Which part of body was affected? What type of injury did the employee receive?

What was the employee doing just before the accident occurred?

How did the injury occur?

What object or substance directly harmed the employee? Name and phone # of witness

Where did the accident occur? (street address, city, state, and county) To whom was it reported?

Initial treatment (check one)

None Emergency room Hospital stay over 24 hrs Minor on-site Clinic/Hospital

Name and address of treating doctor or other health care professional Name and address of facility where treated

If death resulted from an occupational disease (i.e., silicosis, asbestosis, anthracosis, etc.) give names of employers where the exposure occurred and dates of employment (attach additional sheet if needed).

Employer Dates of employment

Employer Dates of employment

For Division Use Only

FEIN Carrier claim #

Policy # Adjuster Code Block #

1. Name of Mortuary

Address

2. Amount of funeral expenses Has same been paid?

3. Was employee married on the date of the injury? Yes No

4. If married, provide:

a. Full name of surviving spouse

b. Present address and phone # of surviving spouse

c. Was surviving spouse living with employee at the time of death? Yes No

d. Social Security # of spouse

e. Birth date of spouse

5. Was employee previously married? Yes No If so, provide name and address of former spouse(s)

6. Provide name, date of birth, SS #, and present address of all children of the employee under the age of eighteen (18) years:

7. Provide name, date of birth, SS #, and present address of any child of the employee over the age of eighteen (18) and under the age of twenty-one (21) who was dependent upon the employee for support and was a full-time student at an accredited school at the time of employee’s death:

8. Provide name, date of birth, SS #, present occupation, relationship to the employee and present address of any other person who was wholly or partially supported by the employee at the time of employee’s death:

9. Other than amounts received from the employee, what income did each of the dependents listed in #8 receive, during the year immediately preceding the death of the employee?

10. Indicate whether each of the dependents listed in #8 was incapable or actually disabled from earning his/her own living, and if so, for what period of time.

Attach a copy of employee’s marriage certificate(s), death certificate, and children’s birth certificates.

State of Colorado, ss.

County of

Affidavit of Claimant

being first duly sworn upon oath deposes and says, that the statements made in the foregoing notice and claim are true.

Subscribed and sworn to before me this day of ,

My commission expires

CALCULATION OF AVERAGE WEEKLY WAGE

To determine the weekly wage, calculate the following:

• First, calculate the employee’s average weekly wage. Multiply the average number of hours worked per week (excluding overtime) times the hourly wage.

• If the employee was paid by the month, multiply the monthly salary times 12 (months) and divide by 52 (weeks).

• If the employee was paid bi-weekly (every other week), take the bi-weekly salary and divide by 2.

• If the employee was paid on a per diem basis, multiply the daily wage times the number of days and fractions of days in the week s/he would have worked under the contract of hire if the injury had not occurred.

• Next, determine the average weekly amount of any overtime, tips (as reported to the IRS), commissions, piecework, mileage, board, rent, housing or lodging, etc., provided by the employer.

• If you, the dependent, were covered by group health insurance through this employment, add your cost of converting to a similar or lesser insurance plan and include this cost in the average weekly wage computation.

• Add the totals from each of the above categories to obtain the average weekly wage and insert in Average weekly wage at time of injury field.

DATE OF INJURY/DISEASE

Always include a date of injury. In the case of an occupational disease, use the date the employee was last exposed to the hazard.

INJURY DESCRIPTION

1 Be specific. Examples: “heart attack”; “chemical exposure”, etc.

2 Describe the activity, as well as the tools, equipment or material the employee was using. Be specific.

3 Tell us how the injury occurred.

4 Examples: “concrete floor”; “chlorine”; “radial arm saw”, “beryllium.”

FILING AND BENEFIT INFORMATION

Upon completion, mail or deliver two (2) copies of the Dependent’s Notice and Claim for Compensation to: The Colorado Division of Workers’ Compensation, Customer Service Unit, 633 17th St., Suite 400, Denver, CO 80202-3660.

For benefits and dispute resolution options or to request a copy of the Employee’s Guide, contact the Customer Service Unit at (303) 318.8700 or toll free at (888) 390.7936 for English, or (800) 685.0891 for Spanish.

Website:

GENERAL INFORMATION

When your claim form is received by the Division of Workers’ Compensation, a copy will be sent to the employer’s insurance carrier (insurer).

The insurer has 20 days from receipt of this information to advise, in writing, whether liability will be admitted or denied.

When a person is fatally injured on the job, workers' compensation provides weekly payments to the surviving dependent(s) and up to $7,000 for funeral expenses.

NOTICES

If a child support obligation is owed, compensation benefits may be attached and payment may be withheld and forwarded to the obligee.

You must provide written notice of any award for social security, pension, disability or other source of income that might reduce your compensation benefits.

It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purposes of defrauding or attempting to defraud the company.