Workers' Compensation Form

Final Admission of Liability

Workers’ Compensation (WC) # Average Weekly Wage

Claimant’s Name Date First Payment of TTD

Social Security # Date of MMI

Date of Injury Date First Payment of PPD

Carrier Claim # Employer

Insurance Carrier Third Party Administrator

NOTICE TO CLAIMANT:

This Final Admission of Liability is a legal document listing benefits that have been or will be paid. You have the right to disagree or object to benefits admitted or not admitted. If you do not object to this admission within 30 calendar days of the date of the final admission, your file will automatically close. Objection information is attached.

If you disagree with the benefits admitted or not admitted you must do the following:

1. Within 30 days, complete the attached objection form or write a letter to the Division of Workers’ Compensation, 633 17th St., Suite 400, Denver, CO 80202-3660 with a copy to the insurance carrier or self-insured employer stating that you object to this admission. You must also file an application for hearing with the Office of Administrative Courts on any disputed issues.

2. Within the same 30 days, if you disagree with the date of MMI or whole person impairment rating, complete the attached I. Notice and Proposal and II. Application for a Division Independent Medical Examination (DIME) and send it to the insurance carrier or self-insured employer and the Division.

3. If a DIME is requested, you are not required to file an application for hearing until after the DIME is completed.

BENEFIT SUMMARY

Medical (PPD): to Date (total) $

Disfigurement (total) $ Whole Person Impairment % Age

Vocational Rehabilitation Services (total) $

or

Temporary Total Disability (TTD) (total) $ Scheduled Impairment % Part of Body Code

Temporary Partial Disability (TPD) (total) $ Scheduled Impairment % Part of Body Code

Stipulation $

Permanent Total Disability (PTD) $

Safety Rule Violation Offset (Attach Calculation)

Waiting Period Dates:

Admit to Maintenance Care after MMI? Yes No Pursuant to Dr. 's medical report dated

Remarks and basis for permanent disability award:

BENEFIT HISTORY

Type of Benefits Time Periods Weeks Rate per Week $ Totals $

Type of Benefits Time Periods Weeks Rate per Week $ Totals $

Type of Benefits Time Periods Weeks Rate per Week $ Totals $

Type of Benefits Time Periods Weeks Rate per Week $ Totals $

Type of Benefits Time Periods Weeks Rate per Week $ Totals $

Type of Benefits Time Periods Weeks Rate per Week $ Totals $

Type of Benefits Time Periods Weeks Rate per Week $ Totals $

The above time periods include the dates specified. Amount of Interest Paid $

Amount of Penalties Paid $

Amount Overpaid $ (See Remarks)

Claims Representative Phone # Toll-Free Phone #

Address

CERTIFICATE OF MAILING

Copies of this document were placed in the U.S. mail or delivered to the following parties this day of , .

List names and addresses of all persons copied:

Claimant:

Claimant's Attorney:

Employer:

Carrier's Attorney

Division of Workers’ Compensation, 633 17th St., Suite 400, Denver, CO 80202-3626

Objection to Final Admission of Liability

Name of Claimant: Social Security #:

Workers’ Compensation (WC) #: Date of Injury:

Insurance Carrier Claim #: Date of Final Admission:

I contest this admission. Check the boxes that apply:

I am requesting a Division Independent Medical Examination (DIME).

I will mail or deliver an Application for Hearing form on disputed issues to the Office of Administrative Courts within 30 calendar days of the date of the Final Admission.

I. Notice and Proposal

Requesting party: Claimant Carrier

WC#: Date of Injury: Need for Interpreter? Yes No

Claimant’s Name: Phone #:

Email:

Claimant’s Address:

City: State: Zip:

*Claimant’s Attorney: Phone #:

Email:

Address:

Carrier: Phone #:

Adjuster: Phone #:

Email:

Address:

*Carrier’s Attorney: Phone #:

Email:

Address:

I propose any one of the following physicians to conduct the DIME:

1) 2) 3)

7. Notice Regarding PAYMENT FOR DIME:

I hereby certify that I will be responsible for payment of the DIME to the DIME Physician.

II. Application for a Division Independent Medical Examination (DIME)

WC#: Date of Injury:

Claimant Name:

Medical Reason for DIME

The Physician will consider the issues of Maximum Medical Improvement, Permanent Impairment, and Apportionment.

Check specific Region(s) and part(s) of the body and/or conditions to be evaluated.

Total Number of Regions Checked:

Region 1: Upper Extremity

Right Left

Hand

Wrist

Elbow

Shoulder

Carpal Tunnel

CRPS

Thoracic Outlet Syndrome (TOS)

Region 2: Lower Extremity

Right Left

Foot

Ankle

Knee

Hip

CRPS

Region 3

Psychological

Traumatic Brain Injury (TBI)

Region 4: Spine

Cervical

Thoracic

Lumbar

Pelvis

Sacroiliac Joint

Region 5: Ear, Nose and Throat (ENT)

Ear (Hearing)

Face

Temporomandibular Joint (TMJ)

Vestibular Disorder

Nose and Throat

Region 6: Other

Digestive

Hernia

Cardiovascular

Hematopoietic

Endocrine

Skin

Urinary & Reproductive

Respiratory/Pulmonary

Visual

Preferred geographical location of examination:

Physician Selection Process

Medical Provider History

List the name AND address of each physician who has evaluated or treated the claimant for this and/or any other medical condition or injury. If a physician assigned an MMI date or an impairment rating, list the information. At least one MMI date must be listed for the DIME to proceed.

Physician Name Physician Address MMI Date % Rating

Physician Name Physician Address MMI Date % Rating

5. PAYMENT for DIME: Check ONE box only.

$1,000 - If less than two (2) years after the date of injury and/or less than three (3) body regions.

$1,400 - If two (2) or more years but less than five (5) years after the date of injury and/or three (3) or four (4) body regions.

$2,000 - If five (5) or more years after the date of injury and/or five (5) or more body regions.

The requesting party will be responsible for payment of the DIME to the selected physician unless an order of indigence has been granted.

If parties agree on a DIME physician during the negotiation process the parties shall agree upon a fee with the physician.

6. CERTIFICATE OF MAILING

Copies of this document were sent to the Division and the following parties this day of , .

List names and addresses of all persons copied:

Claimant:

Claimant’s Attorney:

Carrier:

Carrier’s Attorney: