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Fill and Sign the Supplemental Report of Return to Work Coloradogov Form

Fill and Sign the Supplemental Report of Return to Work Coloradogov Form

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Open the document and fill out all its fields.
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Colorado Workers’ CompensationSupplemental Report of Return To Work Workers’ Compensation (WC) #Date of InjuryEmployee NameCarrier Claim #Social Security #EmployerPurpose:The purpose of this form is to provide information to determine the accurate payment of temporary disability benefits.Instructions:1.This form may be completed by the employee or employer.2.This form should be completed each time the employee returns to work at full or reduced wages.3.This form should be forwarded to your workers’ compensation carrier.1. Last day employee worked2. Date employee returned to work3. Employee’s return-to-work-wages (Check the box that applies)+Full Wages+Reduced Wages (Provide wage information to the claims adjuster every 2 weeks during periods of wage loss)Additional Information Completed by (Check the box that applies) +Employee+Employer NameDate Address Phone #( ) Fax # ( ) WC12 Rev 07/03

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The best way to complete and sign your supplemental report of return to work coloradogov form

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