Fill and Sign the Workers Compensation Claims State Farm Form

WC 106 Rev.05/05 COLORADO DIVISION OF WORKERS’ COMPENSATION FIRST REPORT TRANSMITTAL Submitted By:Company Name: ______________________________________________Block # or Adjustor Code: _______________________________________Check One ___ Adjusting Firm ___ Carrier ___ Self-InsuredPhone # (____)_____________Fax # (____)_______________Mailing Address: ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________Submitted On Behalf Of: (if submitted by Adjusting Firm)Carrier Name __________________________________________Carrier Block #_________Carrier Claim # Employer NameClaimant NameWC# Division AssignedTransmittal Page _______ of _____ pages. Number of First Reports Attached ______ SEE INSTRUCTIONS ON REVERSE SIDE WC 106 Rev.05/05 INSTRUCTIONS The First Report Transmittal Form (Transmittal) is used by the carrier or adjusting firm to submit Employers First Reports of Injury (FROI). The Transmittal will be returned via fax noting the Workers’ Compensation number (WC#) assigned by the Division. This WC# must be listed on all future documents relating to the claim.The Transmittal MUST be placed on top of the FROIs. List the FROIs on the Transmittal in Carrier Claim Number order.Use one transmittal per carrier. Do not combine carriers on a transmittal.Company Name: List the name of the adjusting firm, carrier, or self-insured submitting the form.Check One: Check the box that identifies the type of entity submitting the form.Block # or Adjustor Code: If the type of entity submitting the transmittal is a carrier or self-insured, list the block # that identifies the carrier or self-insured. If the type of entity submitting the transmittal is an adjusting firm, list the adjustor code.Mailing Address: List the mailing address of the adjusting firm, carrier, or self-insured submitting the form.Phone #: List the telephone number of the adjusting firm, carrier, or self-insured submitting the form.Fax #: List the Fax number of the adjusting firm, carrier, or self-insured submitting the form.Carrier Name: If an adjusting firm submits the transmittal, list the name of the carrier or self-insured associated with the attached FROIs.Carrier Block #: If an adjusting firm submits the transmittal, list the block number assigned to the carrier or self-insured associated with the attached FROIs.Carrier Claim #: List the claim number assigned by the carrier or self-insured.Employer Name: List the name of the employer associated with the claim.Claimant’s Name: List the name of the claimant.WC#, Division Assigned: Do not complete. The Division will assign the Workers’ Compensation number. Transmittal Page __ of __ pages: List the page number of the transmittal and the number of total transmittal pages. Number of First Reports Attached: List the number of FROIs attached to the transmittal.Mail or Deliver to: Division of Workers' Compensation 633 17th St., Suite 400Denver, CO 80202-3660 303.318.8700