Fill and Sign the Division of Workers Compensation Settlement Checklist and Routing Sheet Form

WC105 Rev 06/05 DIVISION OF WORKERS’ COMPENSATION SETTLEMENT CHECKLIST AND ROUTING SHEET Customer Service 303.318.8700 Claimant’s name: ______________________________________________________________ Social Security Number ____________________________List all workers’ compensation (WC#) numbers included in this settlement:WC#: _______________________DOI______________WC#: _______________________DOI______________WC#: _______________________DOI______________WC#: _______________________DOI______________Claimant’s Attorney ________________________________ Reg. # _______________________Respondent’s Attorney _____________________________ Reg. # _______________________Other Attorney ____________________________________ Reg. # _______________________Other Attorney ____________________________________ Reg. # _______________________ Other Attorney ____________________________________ Reg. # _______________________Type of settlement (check one):/ Full and Final Settlement (F)/ Partial Settlement (P)/Third Party (Subrogation) Settlement (T)/Structured Settlement: Limited Period of Time (S)/ Structured Settlement: Lifetime (L)Total amount of settlement award (Include lump sum plus present value of any structured settlement)$_______________________________Carrier Portion: $_________________________ _SIF Portion: $_________________________ _Major Med Portion $__________________________Verify the following by checking the boxes provided:1. Claimant is represented by an attorney . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . / 2. Workers’ compensation numbers are correct . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . /3. Order and settlement document contain caption with WC number(s), claimant’s name, employer’s name and insurance carrier’s name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . / 4. Settlement document has original signatures of all parties . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . /5. Claimant’s signature on settlement document is notarized . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . /6 Waiver of right to reopen is properly conditioned . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . /7. Documents include a standard order containing language required by the Division . . . . . . . . . . . . . . . . . . . . . . . . . . .. /8. Date claimant signed the settlement document is entered on the order as the date of settlement . . . . . . . . . . . . . . . /9. Settlement document provides that the claimant has personally reviewed the stipulation with an attorney and waives the right to a personal appearance before the Director or Administrative Law Judge . . . . . . . . . . . . . . . . . . . . .. . . . . . / For DOWC use onlyY N _____________ Y N _____________ Y N _____________ Y N _____________ Y N _____________ Y N _____________ Y N _____________ Y N _____________ Y N _____________10. All hearings before the Office of Administrative Courts and appeals before ICAP, Court of Appeals and Supreme Court have been vacated or dismissed for the workers’ compensation cases listed in this settlement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . /11. All mediation, prehearing and settlement conferences before the Division of Workers’ Compensation have been canceled . . . . . . . . . . . . . . . . . /I certify that I reviewed the attached settlement document and order, and that they contain all of the above information.__________________________________________ _____________SignatureDate________________________________________________________________Print NameRepresentative for: / Claimant / RespondentResubmitted (if initially rejected) __________________________________________________________________________________________________________ _____________ Print NameSignature Date Representative for: / Claimant / RespondentInstructions for document return: /Will pick up at Customer Service /Please mail (Division will mail only if sufficient copies, with addressed, stamped envelopes for all parties are attached)Contact person for information:________________________________ ____________________________ Name Phone number Contact person for document pickup:________________________________________ __________________Name Phone number This form must be completed and submitted with the settlement document and order. Include a mailing certificate if the order is to be mailed. Submit the original settlement document and copies for all parties listed on the mailing certificate. Failure to correctly complete and submit all documents may result in rejection or return of the settlement. Settlement documents for claimants not represented by an attorney must be submitted directly to the Office of Administrative Courts. Do not complete this form if the claimant is unrepresented.Division of Workers’ Compensation Use Only: / Approved Date: __________________________ By:_________________________________________________________________ / Rejected (see # ____ above) Date: __________________________ By:_________________________________________________________________Person picking up documents: _____________________________________________________ _________________________________________________Print Name SignatureOn behalf of: ____________________________________________________________________________ Date: ________________________________ WC105 Rev 06/05 Mail or deliver all documents to: Division of Workers’ Compensation, Customer Service 633 17th St., Suite 400, Denver, CO 80202-3660