Fill and Sign the Colorado Final 497300795 Form

COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT DIVISION OF WORKERS’ COMPENSATION FINAL PAYMENT NOTICE Reason for Filing - Whenever a worker’s compensation claim has been closed, the Insurer shall file a Final Payment Notice within 60 days of the date of closure. The information on this form captures the total cost of claims for statistical reporting of trends and for reports to the legislature. This Final Payment Notice is being filed for the following reason: (check one) Full and Final Settlement Final Order Closure Order Final Admission Other Type of Filing (check one) Original Amended Date Mailed/Delivered WC # Insurer/TPA Claim # Claimant’s Name Insurer Name SS # TPA Name Date of Injury Adjuster Name Date of MMI Adjuster Phone Total Paid TTD # of Weeks Paid # of Days Paid TPD Employer Paid (§ 8-42-124, C.R.S.) Whole Person PPD % Scheduled PPD % Part of Body % Part of Body (See Part of Body Table) % Part of Body % Part of Body PTD Part of Body Table Final Pay POB Codes Description Corresponding Admission Codes (For Reference Only) 13 Ear(s) 35, 36 14 Eye(s) 32, 33 31 Upper Arm 01 34 Wrist 35 Hand 03 36 Finger(s) 07, 08, 09, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22 37 Thumb 04, 05, 06 52 Upper Leg 23 55 Ankle 56 Foot 25 57 Toes(s) 29, 30, 31 58 Great Toe 26, 27, 28Disfigurement Hospital Costs Physician Costs Other Medical Costs Settlement/Stipulation Legal Costs Interest Paid Penalties Paid Fatal Benefits Date of Death Funeral Costs Vocational Rehabilitation Maintenance (RMB) WC 25 Rev. 01/06 Page 1 Block # Adj. Code Other Rehabilitation Maintenance (VR Services) WC 25 Rev. 01/06 Page 2 Block # Adj. Code INSTRUCTIONS/DEFINITIONS Report the full amount paid by benefit type. Report cumulative costs on any subsequent Final Payment Notices filed for the same claim. Reason for Filing Check the appropriate category reflecting the reason for filing. If Other, please specify. Type of Filing Check Original if this is the first Final Payment Notice filed by this party on this claim. A Final Payment Notice is required to be filed 60 days after closure of a claim. Check Amended if the Original Final Payment Notice was filed in error or if additional benefits were paid after the original filing. Report cumulative totals on all amended Final Payment Notices. Date Mailed Date Final Payment Notice was mailed or delivered to the Division. Claim Demographics WC # Number assigned by the Division to identify the specific claim. If the Settlement involves multiple claims, report the settlement amount on only one claim. Report amounts paid on the other claims (where any benefits were paid) on a separate Final Payment Notice for each claim. Claimant’s Name Injured worker’s legally recognized full name. SS # Number assigned by the Social Security Administration to identify the employee. Date of Injury Date of the accident or date of notice of an occupational disease or exposure. Date of MMI Date of maximum medical improvement (MMI) after which further recovery from or improvement to an injury or disease can no longer be anticipated based on reasonable medical probability. Insurer/TPA Claim # Number assigned by the Insurer or Third Party Administrator to identify the specific claim. Insurer Name Name of the insurer or self-insured employer assuming financial responsibility for the claim. TPA Name Name of the Third Party Administrator contracted to adjust the claim, if applicable. Adjuster Name Name of the person administering the claim. Adjuster Phone Telephone number of the adjuster. Total Paid List actual amounts paid prior to this filing. TTD Temporary Total Disability (TTD) benefits paid for the period claimant was unable to earn any wages and not reported as Employer Paid benefits (§ 8-42-124). # of Weeks Paid Number of whole weeks paid for the listed TTD benefits. # of Days Paid Number of days paid for the listed TTD benefits, not included in the number of weeks paid. TPD Temporary Partial Disability (TPD) benefits paid for the period during which the claimant was unable to earn full wages and not reported as Employer Paid benefits (§ 8-42-124). Employer Paid Lost-time benefits reimbursed to the employer pursuant to § 8-42-124 and not reported as TTD or TPD benefits in the above categories. Whole Person PPD Permanent Partial Disability (PPD) benefits paid for permanent medical impairment not listed on the schedule. List only actual amounts paid. Whole Person % Permanent impairment rating for impairment not listed on the schedule. Scheduled PPD Permanent Partial Disability (PPD) benefits paid per the statutory schedule at § 8-42-107(2). List only actual amounts paid. Scheduled Injury % Permanent impairment rating for impairment to the scheduled part of body. Part of Body The code corresponding to the part of body for the scheduled injury impairment rating. See Part of Body Table on the front of the form. Use the code in the first column of the Table. PTD Permanent Total Disability (PTD) benefits paid for medical impairment and other factors that render the claimant unable to earn any wages. Disfigurement Benefits paid for permanent scarring. Hospital Costs Total paid to hospitals for services for this claim. Physician Costs Total paid to physicians for services for this claim. Other Medical Costs Total paid for medical services not otherwise reported for this claim. Settlement/Stipulation Settled amounts over and above other amounts paid and not reported elsewhere on this form. Report cumulative costs on any subsequent Final Payment Notices filed for the same claim. Legal Costs Total respondents’ legal expenses paid for this claim. Interest Paid Total interest paid for this claim. Penalties Paid Total penalties paid for this claim. Fatal Benefits Compensation benefits paid for death resulting from a work-related accident or occupational disease. Date of Death On a fatal claim, the date the injured worker died. Funeral Costs Total funeral expenses paid for this claim. Vocational Rehabilitation Maintenance Total weekly maintenance benefits paid while the claimant participated in a vocational rehabilitation program. Other Rehabilitation Maintenance Total paid vocational rehabilitation evaluation and education services plus other vocational services not otherwise reported for this claim. Insurer Identifying Information Block # Three-digit Division assigned number identifying the insurer or self-insured employer listed above. Adj. Code Two-alpha character Division assigned code identifying the TPA listed above.