Fill and Sign the Important Claims Timelinescolorado Department of Labor Form

WC 25 Rev. 01/06 Page 1 Block #Adj. Code COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT DIVISION OF WORKERS’ COMPENSATION FINAL PAYMENT NOTICE Reason for Filing - Whenever a worker’s compensation claim has been closed, the Insurer shall file a Final Payment Notice within 60 days of the date of closure. The information on this form captures the total cost of claims for statistical reporting of trends and for reports to the legislature. This Final Payment Notice is being filed for the following reason: (check one)Full and Final Settlement Final OrderClosure Order Final AdmissionOther Type of Filing (check one)OriginalAmendedDate Mailed/DeliveredWC #Insurer/TPA Claim #Claimant’s NameInsurer NameSS #TPA NameDate of InjuryAdjuster NameDate of MMIAdjuster PhoneTotal PaidTTD# of Weeks Paid# of Days PaidTPDEmployer Paid (§ 8-42-124, C.R.S.)Whole Person PPD%Scheduled PPD%Part of Body% Part of Body %Part of Body% Part of Body (See Part of Body Table) PTDDisfigurementHospital CostsPhysician CostsOther Medical CostsSettlement/StipulationLegal CostsInterest PaidPenalties PaidFatal BenefitsDate of DeathFuneral CostsVocational Rehabilitation Maintenance (RMB)Other Rehabilitation Maintenance (VR Services) Part of Body Table Final PayPOB CodesDescriptionCorresponding Admission Codes(For Reference Only)13Ear(s)35, 3614Eye(s)32, 3331Upper Arm0134Wrist35Hand0336Finger(s)07, 08, 09, 10, 11, 12, 13, 14, 15,16, 17, 18, 19, 20, 21, 2237Thumb04, 05, 0652Upper Leg2355Ankle56Foot2557Toes(s)29, 30, 3158Great Toe26, 27, 28 INSTRUCTIONS/DEFINITIONS Report the full amount paid by benefit type. Report cumulative costs on any subsequent Final Payment Notices filed for the same claim.Reason for FilingCheck the appropriate category reflecting the reason for filing. If Other, please specify.Type of FilingCheck Original if this is the first Final Payment Notice filed by this party on this claim. A Final Payment Notice is required to be filed 60 days after closure of a claim. Check Amended if the Original Final Payment Notice was filed in error or if additional benefits were paid after the original filing. Report cumulative totals on all amended Final Payment Notices. Date MailedDate Final Payment Notice was mailed or delivered to the Division.Claim DemographicsWC #Number assigned by the Division to identify the specific claim. If the Settlement involves multiple claims, report the settlement amount on only one claim. Report amounts paid on the other claims (where any benefits were paid) on a separate Final Payment Notice for each claim.Claimant’s NameInjured worker’s legally recognized full name.SS #Number assigned by the Social Security Administration to identify the employee.Date of InjuryDate of the accident or date of notice of an occupational disease or exposure.Date of MMIDate of maximum medical improvement (MMI) after which further recovery from or improvement to an injury or disease can no longer be anticipated based on reasonable medical probability.Insurer/TPA Claim #Number assigned by the Insurer or Third Party Administrator to identify the specific claim.Insurer NameName of the insurer or self-insured employer assuming financial responsibility for the claim.TPA NameName of the Third Party Administrator contracted to adjust the claim, if applicable.Adjuster NameName of the person administering the claim.Adjuster PhoneTelephone number of the adjuster.Total Paid List actual amounts paid prior to this filing.TTDTemporary Total Disability (TTD) benefits paid for the period claimant was unable to earn any wages and not reported as Employer Paid benefits (§ 8-42-124). # of Weeks PaidNumber of whole weeks paid for the listed TTD benefits.# of Days PaidNumber of days paid for the listed TTD benefits, not included in the number of weeks paid.TPDTemporary Partial Disability (TPD) benefits paid for the period during which the claimant was unable to earn full wages and not reported as Employer Paid benefits (§ 8-42-124).Employer PaidLost-time benefits reimbursed to the employer pursuant to § 8-42-124 and not reported as TTD or TPD benefits in the above categories.Whole Person PPDPermanent Partial Disability (PPD) benefits paid for permanent medical impairment not listed on the schedule. List only actual amounts paid.Whole Person %Permanent impairment rating for impairment not listed on the schedule.Scheduled PPD Permanent Partial Disability (PPD) benefits paid per the statutory schedule at § 8-42-107(2). List only actual amounts paid.Scheduled Injury %Permanent impairment rating for impairment to the scheduled part of body.Part of BodyThe code corresponding to the part of body for the scheduled injury impairment rating. See Part of Body Table on the front of the form. Use the code in the first column of the Table.PTDPermanent Total Disability (PTD) benefits paid for medical impairment and other factors that render the claimant unable to earn any wages.DisfigurementBenefits paid for permanent scarring.Hospital CostsTotal paid to hospitals for services for this claim.Physician CostsTotal paid to physicians for services for this claim.Other Medical CostsTotal paid for medical services not otherwise reported for this claim.Settlement/StipulationSettled amounts over and above other amounts paid and not reported elsewhere on this form. Report cumulative costs on any subsequent Final Payment Notices filed for the same claim.Legal CostsTotal respondents’ legal expenses paid for this claim.Interest PaidTotal interest paid for this claim.Penalties PaidTotal penalties paid for this claim.Fatal BenefitsCompensation benefits paid for death resulting from a work-related accident or occupational disease.Date of DeathOn a fatal claim, the date the injured worker died.Funeral CostsTotal funeral expenses paid for this claim.Vocational Rehabilitation MaintenanceTotal weekly maintenance benefits paid while the claimant participated in a vocational rehabilitation program.Other Rehabilitation MaintenanceTotal paid vocational rehabilitation evaluation and education services plus other vocational services not otherwise reported for this claim.Insurer Identifying InformationBlock #Three-digit Division assigned number identifying the insurer or self-insured employer listed above. Adj. CodeTwo-alpha character Division assigned code identifying the TPA listed above.