Fill and Sign the Request for Offset of Liability for Workers Compensation Colorado Form

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 Award 1. _____________________________________________________________________________________________ _____________________________________________________________________________________________ 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 Exposure Approximate Date of Exposure Employer Address of Employer 1. _____________________________________________________________________________________________ _____________________________________________________________________________________________ 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 WC63 Rev. 01/06 settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department of regulatory agencies.” WC63 Rev. 01/06