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Division of Workers' Compensation Settlement Checklist and Routing Sheet

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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:

For DOWC use only
Y
N

1. Claimant is represented by an attorney

Y

N

2. Workers' compensation numbers are correct

Y

N

3. Order and settlement document contain caption with WC number(s), claimant's name, employer's name and insurance carrier's name

Y

N

4. Settlement document has original signatures of all parties

Y

N

5. Claimant's signature on settlement document is notarized

Y

N

6. Waiver of right to reopen is properly conditioned

Y

N

7. Documents include a standard order containing language required by the Division

Y

N

8. Date claimant signed the settlement document is entered on the order as the date of settlement

Y

N

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

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.

Y

N

11. All mediation, prehearing and settlement conferences before the Division of Workers' Compensation have been canceled.

Y

N

I certify that I reviewed the attached settlement document and order, and that they contain all of the above information.

Signature

Date

Print Name

Representative for: Claimant Respondent

Resubmitted (if initially rejected)

Signature

Date

Print Name

Representative for: Claimant Respondent

Instructions 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

Signature

Date:

On behalf of:

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

WC105 Rev 06/05

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What this Settlement Checklist and Routing Sheet Is

The Division of Workers' Compensation Settlement Checklist and Routing Sheet is a standardized administrative form that documents the items, approvals, and routing sequence required to finalize a workers' compensation settlement. It aggregates case identifiers, settlement terms, supporting attachments (medical records, lien waivers, fee calculations), and a reviewer log so each approver can confirm completeness before payment or filing. The routing sheet creates an auditable record of signers, dates, and comments to support regulatory review, satisfy compliance obligations, and reduce rework or delays when claims are closed.

Why a Standardized Checklist Matters

A consistent checklist and routing record reduces omissions and processing time, establishes signer authority, documents consent and attachments, and supports audit readiness and defensible settlement handling under agency and payer rules.

Why a Standardized Checklist Matters

Who Completes and Reviews the Routing Sheet

Relevant parties who complete or review the Division of Workers' Compensation Settlement Checklist and Routing Sheet include claims administrators, defense counsel, agency settlement coordinators, and employer representatives.

  • Claims administrators: verify medical releases, lien clearances, fee calculations, and signatory authority before routing.
  • Defense counsel: confirm release language, allocate attorney fees, and approve settlement terms on behalf of the employer.
  • Agency coordinators: ensure required forms, notices, and routing signatures are present for filing or administrative closure.

Using a standardized sheet reduces back-and-forth, creates a traceable reviewer path, and supports records retention for compliance and future inquiries.

Core Sections to Include on a Professional Routing Sheet

A well-structured sheet groups case identifiers, settlement economics, supporting attachments, routing instructions, signature blocks, and filing directions so reviewers can act efficiently and consistently.

Case Details

Include claimant name, claim number, employer, insurer, date of injury, and assigned adjuster. Accurate identifiers prevent misfiling and ensure the settlement links to the correct claim record.

Settlement Terms

State the gross settlement amount, net distribution, attorney fee percentage or fixed fee, lien resolutions, and any structured payment terms or ongoing obligations.

Attachments

List and attach final release, medical summary, lien waivers, Medicare conditional payment documentation if applicable, fee calculations, and any agency-required forms.

Reviewer Routing

Designate sequential reviewers with role, name, contact, date required, approval checkbox, and a comments field for conditional sign-offs.

Authorizations

Capture claimant signature, counsel signature, employer/authorized representative signature, and notarization or witness details where required; record signer capacity and dates.

Filing Instructions

Specify where to file the approved settlement (agency portal or physical address), required copies, filing deadlines, and whether agency entry or order issuance is needed.

Step-by-Step: Complete and Route the Sheet

Follow a sequential process to ensure every approval and attachment is captured and the final filing is completed without delay.

  • 01
    Prepare: Gather release, medical reports, lien paperwork, and fee calculations before starting the form.
  • 02
    Populate: Enter claim identifiers, settlement amounts, and a checklist of required attachments.
  • 03
    Route: Send to designated reviewers in the ordered routing sequence with target dates.
  • 04
    Finalize: Collect signatures, confirm attachments, then file with the agency or issue payment as instructed.

Configure an Online Routing Workflow

Set up the digital workflow to match your routing order, required fields, authentication level, and notification preferences for consistent eSubmission.

Field Configuration
Signer Order Sequential: Claimant → Counsel → Employer; optional agency review
Authentication Email link with optional SMS code or knowledge-based checks for higher-risk settlements
Required Attachments Release, medical summary, lien waivers, fee calculation, and proof of authority
Notifications Email confirmations at each approval and a final signed packet delivery

Routing Flow — From Preparation to Filing

Typical routing follows document upload, checklist verification, sequential reviewer approvals, final authorization for payment, and submission to the agency or claimant representative.

  • Upload: Attach settlement, releases, and supporting documents to the form.
  • Verify: Reviewer checks checklist, liens, and fee calculations for completeness.
  • Approve: Each reviewer signs, dates, and records any conditional items or comments.
  • File/Pay: Send the approved packet to the agency portal or issue settlement payment per instructions.

Technical Requirements for eSubmission and Signing

Choose a platform that supports secure eSignatures, detailed audit trails, document attachments, and customizable routing to meet agency and employer requirements.

  • Document Formats: Accepts PDF, Word DOCX, and common export formats
  • Integrations: Integrates with Salesforce, NetSuite, Microsoft 365, Google Workspace
  • Authentication: Supports email links, SMS codes, and stronger signer authentication

Ensure the solution complies with ESIGN and UETA, supports HIPAA BAA when handling PHI, provides TLS 1.2/1.3 in transit and AES-256 at rest, and retains a detailed audit trail to meet regulatory and audit requirements.

Essential Information to Include on the Sheet

Claimant Name: Full legal name as on ID
Claim Number: Official claim or file number
Date of Injury: Enter date as MM/DD/YYYY format
Settlement Amount: Gross and net amounts in dollars
Signatures: Signed and dated by required parties
Attachments List: Enumerate and attach supporting documents

Common Preparation Errors to Avoid

  • Missing lien waivers or incomplete lien identification leads to later claim offsets and potential re-opening of claims, increasing administrative burden and legal exposure.
  • Incorrect or inconsistent claimant names, dates, or claim numbers cause misrouting and may delay settlement approval by multiple reviewers or require re-submission.
  • Failure to document signatory authority or to include corporate authorization can invalidate employer signatures or require additional notarization and counsel involvement.
  • Omitting Medicare conditional payment documentation when required can trigger repayment demands and hold settlement funds pending verification.

Consequences of an Incorrect or Incomplete Sheet

Delayed Payments: Payment holds or processing delays
Settlement Voidance: Incorrect releases risk invalidation
Tax Withholding: Backup withholding may apply
Fines and Penalties: Regulatory penalties for improper filings
Liability Exposure: Unresolved liens can create liability
Recordkeeping Violations: Noncompliance with retention laws

Timing Considerations and Typical Deadlines

Timely completion and submission prevents payment holds and regulatory issues; some tasks have statutory or agency-imposed deadlines.

Claimant Notice:

Provide required claimant notices per agency timing

Attachment Submission:

Attach releases and lien waivers before routing for approval

Reviewer Turnaround:

Set internal review targets (e.g., 3–7 business days)

Agency Filing:

File approved settlement per agency instructions promptly

Payment Issuance:

Issue settlement payment after final approvals and any hold releases

Example Scenarios Demonstrating Practical Use

Two concise examples illustrate how a routing sheet clarifies approvals, resolves liens, and expedites settlement processing in common situations.

Insurer Case Study

A carrier consolidated release, fee calc, and lien waivers on one routing sheet to avoid duplicate review and payment delays.

  • The routing order ensured counsel signed before payment.
  • After implementation the carrier reported fewer return-to-sender filings and a more auditable approval trail, reducing administrative rework for high-volume claims.

Agency Case Study

An agency required a routing sheet to verify claimant consent, medical attachments, and fee allocations before issuing final orders.

  • Reviewers used the sheet to fast-track standard cases.
  • The agency observed clearer reviewer accountability and fewer post-approval inquiries about missing attachments or signer authority.

eSignature Pricing and Feature Comparison

Compare typical starting prices and key feature considerations across major eSignature vendors; signNow is listed first per vendor ordering rules.

signNow DocuSign Adobe Sign PandaDoc HelloSign
Starting Price $8/user/mo $15/user/mo $14/user/mo $19/user/mo $15/user/mo
Free Trial 7-day free trial, no credit card required Varies Varies Varies Varies
Bulk Send Yes (Premium+) Yes Yes Yes No
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes Yes Yes No No
Envelope Cap No cap 100 envelopes/user/year Varies Varies Varies

Frequently Asked Questions and Troubleshooting

Answers to common operational and compliance questions about completing, routing, and eSubmitting the Division of Workers' Compensation Settlement Checklist and Routing Sheet.


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