Fill and Sign the Colorado Workers Compensation Form

1 Instructions for Completing the Application for Lump Sum Please read all pages This form is “fillable.” That means you can type the information onto the form from your computer and print the form. You will not be able to save the form onto your computer’s hard drive. When you open the form, click in the “Claimant” box (field), com\ plete the information, and use the tab key to navigate to the next field. Do not use the Enter key; pressing the Enter key will only page down. Each field has been limited. This means that you cannot continue to type information into a field if it doesn’t fit into the space provid\ ed. Use numbers only to fill in the fields for phone number and dollar amounts. Do not use dashes, parentheses or dollar signs; when you tab out of the field, it will fill in automatically. If a dollar amount\ contains cents, do type the period. To fill in a check box, click inside the box with your mouse. To clear or delete all the information you have typed onto the form, click on the red “ Clear Entire Form” button. To clear all information on a single page, click on the red “ Clear This Page” button. To change the information in one field, use the backspace or delete key. 2 “Clear Entire Form ” button Clears all information at once “ Clear Tis Page ” button Clears all information on this page 3 “Check Box ” Click in box WC62 Rev 01/06 Page 1 of 2 COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT DIVISION OF WORKERS’ COMPENSATION APPLICATION FOR LUMP SUM (Permanent Partial, Permanent Total and Dependents’ Benefits) Claimant ________________________________________ W.C.# _________________________________________ Date of Injury _____________________________________ Employer ______________________________________ Insurance Carrier _______________________________ Insurance Carrier Claim #_______________________________ COMPLETE, SIGN AND MAIL (O R DELIVER) TWO COPIES TO THE INSURANCE CARRIER HANDLING YOUR CLAIM. FAILURE TO FORWARD AND/OR SIGN THE APPLICATION MAY DELAY PROCESSING OF Y\ OUR REQUEST. NOTE: A lump sum cannot be granted by the Director of the Division of Workers’ Compensation until SIX (6) MONTHS have elapsed from the date of injury or death, and there has been a final award of permanent benefits. The maximum lump sum allowable is $37,560, including any previously paid lump sums. 1. Name of applicant ____________________________________________ Phone # (______)______________________ Address _______________________________________________________________________\ __________________ Street City State Zip Code 2. Date of applicant’s birth _________________________ 3. If applicant is other than claimant, state family relationship ___________________________________________ 4. Basis of disability or death benefit award Final Admission Final Order 5. Date of disability or death benefit award ________________________________________ Month Day Year 6. Amount requested $ ___________________________________ 7. Applicant is presently: Receiving Social Security Benefits Receiving pension benefits or other income Monthly Amount $ __________________________ Monthly Amount $ __________________________ I accept the Admission of Liability as file d with regard to permanent benefits. I und erstand that in accordance with section 8-43-406 of the Colorado Workers’ Compensation Act, a four percent per annum discount is subtracted from the total award. Dated this ______________ day of ___________________________, ________. Day Month Year ____________________________ __________________ \ Applicant’s Signature DELIVER OR MAIL TWO COPIES TO THE INSURANCE CARRIER The insurance adjuster will complete the second page of this form and mail a copy to you and to the Division of Workers’ Compensation. Block # Adj. Code WC62 Rev 01/06Page 2 of 2 THIS PAGE IS TO BE COMPLETED BY THE INSURANCE AJDUSTER . Instructions: Please complete the blanks and forward the entire form to the Division of Workers’ Compensation within 15 calendar days of the mailing date on the application. Pursuant to Rule 5-10 (A) of the Rules of Procedure, a copy of the reply should be sent to the applicant,\ or attorney if represented. The insurance adjuster may calculate and issue a lu mp sum (without an order by the Director), when all the following facts are true: • The date of injury is on or after April 29, 1992; • The award is for whole person impairment; and • The amount of the award is $10,000 or less. Claimant Name: WC#: Type of Award – Check one PPD PTD Fatal 1. Total award for permanent partial disability : $ 2. Permanent partial disability paid to date (including previous lump sums and discounts in # 4, and any overpayments in #5): $ 3. Permanent partial disability balance due (Total award for PPD less PPD paid to date should equal PPD balance due ): $ 4. Has a lump sum of $10,000 been paid? ........................................................................\ ......... Yes No 5. Is there an overpayment of temporary benefits? ................................................................... Yes No If so, what is the amount of the overpayment? ................................................................ $ 6. Date to which permanent partial disability paid: 7. Compensation rate (for PPD, PTD or Fatal benefit) prior to offset(s): $ 8. If you object to the request for a lump sum, please state the reason: Adjuster Name: Phone #: ( ) Carrier Name: Fax #: ( ) Carrier Address: (Street Address/PO Box) (City) (State) (Zip) CERTIFICATE OF MAILING: Copies of this document were placed in the U.S. mail or delivered to the following parties this day of , . (day) (month) (year) List names and addresses of all persons copied: Claimant: Claimant Attorney: Respondent Attorney: Division of Workers’ Compensation, 633 17th St., Suite 400, Denver Co 80202-3660 By: (Insurance Adjuster or Representative) Notice to Applicant: If you object to this response, no tify the Division of Workers’ Compensation in writing of your objection within 10 (ten) days from the date of the above certificate of mailing. Mail this objection to the Division of Workers’ Compensati on, 633 17th Street, Suite 400, Denver CO 80202-3660.