Fill and Sign the Workers Compensation is Your Injury or Illness Work Related Form

Workers' Compensation (WC) # Average Weekly Wage Claimant's Name Date First TTD Payment Social Security# Date of MMI Date First Payment of PPD Carrier Claim # Employer Insurance Carrier Third Party Administrator Medical to Date (total) $ Disfigurement (total) $ Vocational Rehabilitation Services (total) $ Whole Person Impairment Temporary Total Disability (TTD) (total) $ Temporary Partial Disability (TPD) (total) $ Scheduled Impairment % Part of Body Code Stipulation $ Scheduled Impairment % Part of Body Code through x $ x $ through x $ x $ through x $ x $ through x $ Amount of Interest Paid $ Amount Overpaid $ Claims Representative Toll-Free Phone# Address  FINAL ADMISSION OF LIABILITY (For Injuries Occurring On or After August 5, 1998) Date of Injury NOTICE TO CLAIMANT: This is an important legal document that can affect your rights. YOU ARE HEREBY NOTIFIED that a final determination has been made of the amount of benefits to be paid in this case. Benefits have been or will be paid in the amounts shown below. If you disagree with the amount or type of benefits which the carrier or self-insured employer has agreed to pay, WITHIN 30 DAYS OF THE DATE OF THIS FINAL ADMISSION, you must:1. Complete the attached Objection form or write a letter, within 30 days, to the Division of Workers' Compensation, 1515 Arapahoe St., Denver, Colorado 80202-2117, with a copy to the insurance carrier or self-insured employer, stating that you object to this admission of liability; AND 2. If you have any disputed issues, mail or deliver an Application for Hearing, within 30 days, to the Division of Administrative Hearings, 1120Lincoln St., 14th Floor, Denver, CO 80203 (on the western slope, mail to 222 South 6th, #414, Grand Junction, CO 81501); AND/OR 3. If you disagree with either the date of MMI or whole person impairment determinations, complete the Notice and Proposal to Select an Independent Medical Examiner form, within 30 days, and send it to the insurance carrier. You must propose the name of one or more doctors, to conduct an Independent Medical Examination (IME), if a Division IME pursuant to C.R.S. section 8-42-107.2 C.R.S. has not already determined that issue. If you do not object to this admission, your case will automatically be closed as to the issues admitted in the final admission. Objection information is attached. See page 2 for codes, definitions and other important notices. BENEFIT SUMMARY (Check box & list amount for admitted benefits) Permanent Partial Disability (PPD): % Age orPermanent Total Disability (PTD) Safety Rule Violation (See page 2 for Part of Body Codes) Offset (Attach Calculation) Position on Medical Benefits after Maximum Medical Improvement (MMI): Remarks and basis for permanent disability award: (Attach additional pages, if needed) BENEFIT HISTORY Type of Benefits Time Periods WeeksRate per Week Totalsthrough==$=through=$==$=through==$=$==$==$The above time periods include the dates specified. Amount of Penalties Paid $ (Attach additional pages, if needed) (See Remarks) Phone # CERTIFICATE OF MAILING: Copies of this document were placed in the U.S. mail or delivered to the following parties thisday of IList names and addresses of all persons copied: NameAddressClaimant:Claimant's Attorney: Employer:Carrier's Attorney: Division of Workers' Compensation, 1515 Arapahoe Street, Denver, CO 80202-2117 By:Block # Adj. Code WC145 Rev 6/99.00 Page 1 of 1 See page 2 for important notices and codes NOTICE TO CLAIMANT: YOU ARE HEREBY NOTIFIED that if a child support obligation is owed, compensation benefits may be attached, and payment of the child support obligation may be withheld and forwarded to the obligee pursuant to C.R.S. section 8- 42- 124 and C.R.S. section 26-13-122(4). YOU ARE FURTHER NOTIFIED that you must provide written notice of any award for social security, pension, disability or other source of income that might reduce your compensation benefits. This notice must be sent to the insurance carrier or self-insured employer within 20 days after learning of the payment or award. Failure to report may result in suspension of your benefits pursuant to C.R.S. section 8-42- 113.5. BENEFITS:Compensation benefits are paid by insurance carriers for compensable injuries. Temporary disability benefits are paid every two weeks. Medical Benefits - Current medical benefits for medical, hospital and surgical supplies, prescriptions, crutches, apparatus and vocational rehabilitation. Maximum Medical Improvement (MMI) - The date when any medically determinable physical or mental condition as a result of injury has become stable and when no further treatment is reasonably expected to improve the condition. Facial or Bodily Disfigurement - Serious, permanent disfigurement about the head, face or parts of the body normally exposed to public view. Benefits are not to exceed $2000. Temporary Total Disability (TTD) - Total disability of more than 3 working days. If disability lasts for more than 14 calendar days, compensation shall be paid from the day the claimant left work. Compensation is payable at the rate of 66',''f 1/4% of the average weekly wage in effect at the time of the injury not to exceed the statutory maximum. A loss of fringe benefits specifically enumerated in the statute should be included in the calculation of the average weekly wage. Temporary Partial Disability (TPD) - Temporary partial disability of more than three working days. Compensation is payable at the rate of 66 11V 1/4% of the difference between the employee's average weekly wage at the time of injury and the employee's average weekly wage during the continuance of the temporary partial disability not to exceed the statutory maximum. Permanent Partial Disability (PPD) - For dates of injury on or after July 1, 1991, an award for PPD is based on permanent impairment as defined by the authorized treating physician and is limited to the part of the body that is affected. Whole Person Impairment - Loss of function affecting body parts, including mental, not listed under the schedule below. Scheduled Impairment - Loss of function affecting the toes, feet, legs, fingers, hands, arms, eyes, vision and deafness. Codes for scheduled impairment ratings used by insurance carriers are listed below: Part of body codes for scheduled ratings: 01 Arm@ Shoulder 03 Hand@ Wrist 04 Thumb @Metacarpal 05 Thumb @ Proximal 06 Thumb @ Distal 07 Index @ Metacarpal 08 Index@ Proximal 09 Index@ Second 10 Index @ Distal 11 Middle @ Metacarpal 12 Middle @ Proximal 13 Middle@ Second 14 Middle @ Distal 15 Ring @ Metacarpal 16 Ring @ Proximal 17 Ring @ Second 18 Ring@ Distal 19 Little @ Metacarpal 20 Little @ Proximal 21 Little@ Second 22 Little @ Distal 23 Leg @ Hip 25 Leg. @ Foot, Heel, Ankle 26 Great Toe @ Metatarsal 27 Great Toe@ Proximal 28 Great Toe @ Distal 29 Other Toe @ Metatarsal 30 Other Toe@ Proximal 31 Other Toe @ Distal 32 Eye Enucleation 33 Blindness One Eye 34 Deafness Both Ears 35 Deafness One Ear 36 Total Hearing 2nd Ear If you have any questions or need forms, contact the Division of Workers' Compensation, Customer Service Unit at 303.318.8700 or toll-free at 888.390.7936. WC145 Rev 6/99.00 Page 2 of 2 Name of Claimant: Social Security #- Workers' Compensation (WC) #- Date of Injury: Insurance Carrier Claim #- Date of Final Admission: OBJECTION TO FINAL ADMISSION OF LIABILITY (For Injuries Occurring On or After August 5, 1998) If you disagree with the Final Admission, you must mail or deliver an objection WITHIN 30 CALENDAR DAYS of the date of the Final Admission to the Division of Workers' Compensation and send a copy to the insurance carrier or self-insured employer. Also within 30 days, if you disagree with the determination of Maximum Medical Improvement (MMI), and/or Whole Person Permanent Impairment*, you must propose one or more names of an Independent Medical Examiner, if a Division Independent Medical Examination (IME) has not already determined that issue, by completing the form on the back; AND you must request a hearing on any disputed issues. Otherwise, your claim will be closed as to the issues admitted in the Final Admission of Liability. Please print and complete Sections I and II of this form. Complete the back of this form, if applicable. If you have any questions, or need an Application for Hearing form and/or Application for Independent Medical Examination (IME) form, you may contact the Customer Service Unit at 303.318.8700 or toll-free at 888.390.7936. SECTION I -OBJECTION TO FINAL ADMISSION I contest this admission. Check the boxes that apply: I am proposing the name(s) of an Independent Medical Examiner and requesting an Independent Medical Examination (IME). I have not previously undergone a Division IME that resolved a dispute over maximum medical improvement (MMI), or a whole person permanent impairment determination*. I am completing the Notice and Proposal to Select an Independent Medical Examiner on page 4 of this form. Additional instructions are on page 4. I understand that I will be responsible for the cost of the IME, and I must complete an Application for Independent Medical Examination (IME) form. *Note: If you believe that a scheduled rating should be a whole person rating, you may request an IME. If you disagree with a scheduled rating, you may proceed directly to hearing without an IME. (See definition of scheduled impairment rating and codes on page 2.) I will mail or deliver an Application for Hearing form on disputed issues to the Division of Administrative Hearings within 30 calendar days of the date of the Final Admission. Disputes about MMI and/or whole person impairment ratings are not ready for hearing until an IME has been completed. SECTION 11 -CERTIFICATE OF MAILING Copies of this document were placed in the U.S. mail or delivered to the following parties thisday of List names and addresses of all persons copied: NameAddressClaimant:Claimant's Attorney: Employer:Insurance Carrier: Carrier's Attorney: Division of Workers' Compensation, 1515 Arapahoe Street, Denver, CO 80202-2117 By:(Signature of claimant or claimant's representative) WC145 Rev 6/99 00 Paae 3 of 3 MMIPermanent Impairment MMI and Permanent Impairment WC # Carrier Claim # Social Security # Claimant Name Date of Injury I disagree with the determination by Dr. dated Signature of Requester Phone# Copies of this document were placed in the U.S. mail or delivered to the following parties this day of By: COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT DIVISION OF WORKERS' COMPENSATION NOTICE AND PROPOSAL TO SELECT AN INDEPENDENT MEDICAL EXAMINER Complete Sections I and 11. Please read the information at the bottom of this form. SECTION I Notice and Proposal of Independent Medical Examiner Iand I request a Division IME on the following issue: (check one) I propose any one of the following physicians to conduct the IME: (The physician must be Level II accredited. Information on accredited physicians and the Application for IME form may be obtained by calling the Customer Service Unit listed below.) I understand that I need to talk to the other party to discuss this request. Once the negotiation process is completed, I must submit the Application for IME form to the Division and all parties. SECTION II Certificate of Mailing IList the names and address of all persons copied: NameAddressClaimant:Claimant's Attorney: Carrier:Carrier's Attorney: Division of Workers' Compensation, 1515 Arapahoe Street, Tower 2, Suite 640, Denver, CO 80202-2117 SignatureINFORMATIONAL SUMMARY The following is a brief outline of the Division Independent Medical Examination (IME) process. This general information may not include all circumstances and is not meant as legal advice. If you have any questions, contact the Customer Service Unit listed below. 1. The party requesting the IME (requester) must complete the Notice and Proposal for Independent Medical Examiner form. The requester must send this Notice to the other party. If you are the claimant, the other party is the insurance carrier. If you are the Insurance Carrier, the other party is the claimant or claimant's representative, if applicable. 2.The parties have 30 calendar days to negotiate the selection of the Independent Medical Examiner (physician who will conduct the IME). The requester needs to obtain an Application for Independent Medical Examination (IME), Form WC77, during this time.3.If the parties agree on the Independent Medical Examiner, the requester must schedule the examination promptly with the physician. The requester must also complete the Application for IME form and submit this to the Division of Workers' Compensation, the physician, and the other party. 4.If the parties do not agree on the Independent Medical Examiner, or there is no response to the Notice and Proposal, the insurance carrier must complete the Notice of Failed IME Negotiation, Form WC165. A copy must be sent to the Division and the claimant. The party requesting the IME shall have 30 days from the date of the failure to agree or respond to submit Application for Independent Medical Examination (IME), Form WC77. The Division will select a qualified physician to perform the IME. The parties will be notified by phone of the physician's name within 10 calendar days after receipt of the application for an IME. 5.6.The carrier must submit medical records to the physician and other party at least 14 calendar days before the examination. The claimant must notify the carrier if a language interpreter is needed at least 14 calendar days before the examination. The requester is responsible for paying the interpreter. 7.The requester must make the payment to the IME physician at least 10 calendar days before the examination. 8.The physician is required to mail the IME report to the parties and the Division within 20 calendar days of the examination. 9. If the requester wishes to cancel the IME process, contact the IME Section of the Division immediately. If you have any questions or need an Application for Independent Medical Examination (IME), Form WC77, or any other forms, contact the Division of Workers' Compensation Customer Service Unit at 303.318.8700 or toll free at 888..390.7936. WC145 Rev 11/00