Fill and Sign the Petition to Reopen for Workers Compensation Colorado Form

PETITION TO REOPEN Claimant WC# Claimant’s Address Carrier Claim # Social Security # Claimant’s Phone # Date of Injury Employer Insurance Carrier This matter should be reopened because:  Change in medical condition - Attach documentation  Error - Attach documentation  Mistake - Attach documentation  Fraud - Attach documentation  Overpayment - Attach calculations  Terminate Permanent Total Benefits - Attach statement Requester: (Please check one)  Claimant  Employer  Insurance Carrier Signature of Requester _________________________________________ Date Signed ________________________ CERTIFICATE OF MAILING Copies of this document were placed in the U.S. mail or delivered to the following parties this _________ day of _______________________________, ____________. List names and addresses of all persons copied: Name Address Claimant: Claimant’s Attorney: Employer: Carrier: Carrier’s Attorney: By: ___________________________________________________________________ (Signature) This petition must be provided to the other party and to all attorneys of record . The petition must state the basis for the reopening, and supporting documentation must accompany the request. Once a petition has been filed, the requester may apply for a hearing before an Administrative Law Judge. To request a hearing, contact the Office of Administrative Courts at 303.866.2000 and request an APPLICATION FOR HEARING form. PETITION TO REOPEN INSTRUCTIONS WC37 Rev 01/06 Please read the following instructions carefully. This form must be complete so that the opposing party* has the information to consider your request. Please type or neatly print, and then sign the form. You may want to use the last Final Admission of Liability filed on this claim or, if applicable, the final order to help you fill out this form. Fill in all the blank lines. Claimant: Name of injured worker Claimant’s Address: List the current address for the claimant Claimant’s Phone #: List the current phone number for the claimant Employer: Name of employer that the injured worker was working for on the date of injury WC#: Workers’ Compensation Number - refer to the carrier’s last admission Carrier Claim #: Insurance carrier’s claim file number - refer to the carrier’s last admission Social Security #: Social Security Number - make sure number is correct for the injured worker Date of Injury: Date this injury occurred Insurance Carrier: Name of the insurance company or self-insured employer Check the reason or reasons for reopening the claim. If the request to reopen is based on a change in medical condition, some type of documentation reflecting the change in condition must be attached. If a medical report is submitted, it may include information on the following: the physical condition of the claimant at the time the petition is filed, how the condition has worsened or improved, and a statement relating the disability to the work-related accident or exposure. Documentation for any other reason checked must also be attached. Check the box to indicate whether the person completing the Petition to Reopen (Requester) is the Claimant, Employer, or Insurance Carrier. The requester must sign and date the form. A copy of the completed form and accompanying documentation must be sent to the opposing party* and to all attorneys of record. Fill in and sign the mailing certificate at bottom of the form. List the names and addresses of all the parties to whom you are mailing copies. Make sure to keep a copy for yourself. If the opposing party* does not voluntarily reopen the claim or does not provide a response, you may wish to set the matter for a pre-hearing conference by calling 303.866.5508. If issues cannot be resolved between both parties, you may request a hearing before an administrative law judge. To request a hearing, contact the Office of Administrative Courts at 303.866.2000 and ask to have Application for Hearing forms sent to you. If you do not take any action, the status of the claim remains unchanged. If either party agrees to reopen the claim, the insurer must notify the Division in writing or by admission. *Note to Claimants: The opposing party in your claim is the insurance company or the self-insured employer. The address for the opposing party is on the admission of liability. REOPENING PERMANENT TOTAL DISABILITY BENEFITS: Section 8-43-303(3) of the Colorado Revised Statutes provides: In cases where a claimant is determined to be permanently totally disabled, any such case may be reopened at any time to determine if the claimant has returned to employment. If the claimant has returned to employment and is earning in excess of four thousand dollars per year or has participated in activities which indicate that the claimant has the ability to return to employment, such claimant's permanent total disability award shall cease and the claimant shall not be entitled to further permanent total disability benefits as a result of the injury or occupational disease which led to the original permanent total disability award. Any subsequent permanent partial disability benefits awarded for the same injury or occupational disease shall be decreased by the amount of permanent total disability benefits previously received by the employee. In the absence of an agreement with the claimant to voluntarily reopen and terminate permanent total disability benefits followed by an admission terminating the same, the insurer or self-insured employer must request a hearing before an administrative law judge should it seek to terminate these benefits. IF YOU HAVE ANY QUESTIONS OR NEED HELP IN COMPLETING THIS FORM, CONTACT THE DIVISION OF WORKERS’ COMPENSATION, CUSTOMER SERVICE UNIT 633 17TH STREET, SUITE 400, DENVER, CO 80202-3660 303. 318.8700 OR TOLL FREE AT 888.390.7936 WC37 Rev 01/06