Fill and Sign the Colorado Workers Compensation 497300802 Form

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 (OR DELIVER) TWO COPIES TO THE INSURANCE CARRIER HANDLING YOUR CLAIM. FAILURE TO FORWARD AND/OR SIGN THE APPLICATION MAY DELAY PROCESSING OF YOUR 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 filed with regard to permanent benefits. I understand 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. WC62 Rev 01/06 Page 1 of 2 WC62 Rev 01/06 Page 2 of 2THIS 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 lump 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 17 th St., Suite 400, Denver CO 80202-3660 By: (Insurance Adjuster or Representative) Notice to Applicant: If you object to this response, notify 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’ Compensation, 633 17 th St., Suite 400, Denver CO 80202-3660. Block # Adj. Code