Fill and Sign the Employers First Report of Injury Coloradogov Form

WC63 Rev. 01/06 COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT Division of Workers’ Compensation Special Funds Section REQUEST FOR OFFSET OF LIABILITY TO SUBSEQUENT INJURY FUND Claimant_________________________________________ __W.C. # __________________________________________Employer_________________________________________ _Social Security # __________________________________Insurance Carrier ___________________________________Carrier Claim # ___________________________________Date of Injury______________________________________The ____________________________________________ hereby requests that the Director of the Division of Workers’ (claimant, employer, insurance carrier)Compensation be named as an interested party herein on behalf of the Subsequent Injury Fund. In support of this request, petitioner submits the following information:If an offset is claimed pursuant to Section 8-46-101, C.R.S., complete section A, and if offset is claimed pursuant to Section 8-41-304, C.R.S., complete section B.A.Prior Industrial Disability (Section 8-46-101, C.R.S.)List prior workers’ compensation cases below by employer, number, brief description of injury(ies) and award:Employer W. C. Number Description of Injuries Award1. _____________________________________________________________________________________ ________ ____________________________________________________________________________________________ _ 2. _____________________________________________________________________________________ ________ ____________________________________________________________________________________________ _ 3. ____________________________________________________________________________________________ _ ____________________________________________________________________________________________ _ B.Covered Occupational Disease (Section 8-41-304(2), C.R.S.)Indicate the type(s) of exposure(s) alleged, the approximate dates of each, and the name and location of the employer in whose employ the exposure(s) allegedly occurred. Type of ExposureApproximate Date of Exposure Employer Address of Employer WC63 Rev. 01/061. ____________________________________________________________________________________________ _ ____________________________________________________________________________________________ _ 2. _____________________________________________________________________________________ ________ ____________________________________________________________________________________________ _ (attach additional sheet(s) if necessary)Date of Request _______________________________________________________________________________Signature of Requestor NOTE:A copy of this request and all pleadings, notices, reports and documents thereafter filed must be served upon the Director of the Division of Workers’ Compensation. Submit these with this form to the Division of Workers’ Compensation, Special Funds Section, P.O. Box 300009, Denver, CO 80203-0009. Where an assistant attorney general has entered an appearance for the Director in a case, such service shall be made upon that attorney. C.R.S. Section 10-1-128(6)(a) states: “It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department of regulatory agencies.”