Fill and Sign the Workers Compensation Coloradogov Form

WC70 Rev 01/06 COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT Division of Workers’ Compensation APPLICATION FOR ADMISSION TO THE COLORADO MAJOR MEDICAL INSURANCE FUND W.C. Number _____________________________Insurance Carrier _______________________________________Claimant Name ____________________________Carrier Claim Number ___________________________________Social Security Number______________________Date of Accident/Injury ___________________________________Claimant’s Mailing Address ____________________________________________________________________________ Street Address or P.O. Box ________________________________________________________________________________________________ __City StateZipOn behalf of the above named claimant, we hereby apply for admission to the Colorado Major Medical Insurance Fund. In support of the application, we submit that:I. The insurance carrier or self-insured employer has expended at least $20,000 in medical benefits as defined in Section 8- 42-101(1) C.R.S., as amended, as follows: a. Treating physician expenses (including dental) $_____________________________ _ b.Hospital and nursing expenses $_____________________________ _ c. Other (drugs, apparatus, etc.) $_____________________________ _ d.Vocational rehabilitation services $_____________________________ _ e.Rehabilitation maintenance benefits Number of weeks of RMBs ________$_____________________________ _ Total $_____________________________ _In each category list on a separate sheet, or by inclusion of evidence of payment, actual amounts paid and payee. Do not include attorney fees, penalties, interest, investigative costs or administrative costs. Please submit a complete copy of the carrier’s file.If there is need for further medical benefits please explain briefly and include name(s) of present treating physician(s)Include the name of the authorized primary care physician. (Attach additional pages, if needed)_____________________________________________________________________________________________ ______________________________________________________________________________________________ _II. Are you aware of any third party activity on this claim? ‘ Yes ‘ No If any such action is initiated, claimant agrees to provide prompt and reasonable notice to the Director of the Division of Workers’ Compensation.Date:______________________________________________________________________________________ __Claimant’s Signature WC70 Rev 01/06Date:______________________________________________________________________________________ __Insurance Carrier Representative’s Signature____________________________________________________ __Insurance Carrier Representative’s Phone Number Mail the completed form to: Division of Workers’ Compensation, Special Funds Section, P.O. Box 300009, Denver, CO., 80203-0009C.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 settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department of regulatory agencies.”`