Forms by Number
| Form # | Form Title | Revised | Download Form | |
| WC1 | Employer's Beginning Reports of Injury | 01/06 | Word | |
| WC2 | General Admission of Liability | 07/14 | Talk | |
| WC3 | Notice of One-Time Change are Physician & Authorization since Release of Pharmaceutical Information | 06/15 | Word | |
| WC4 | Ultimate Admission of Liability | 03/19 | Word | |
| WC6 | Entry of Appearance | 01/24 | Word | |
| WC12 | Supplemental Report are Return to Labor | 10/21 | Word | |
| WC15 | Worker's Claim for Compensation (Este formulario debe completarse en Inglés.) | 08/22 | Term | |
| WC18 | Dependent's Notes and Claim for Compensation | 08/22 | Word | |
| WC30 | Labelled Health Service Services Disclosure Forms | 11/07 | News | |
| WC34 | Request to Erase (Redact) Medicine Information from an Audio Recording | 08/09 | Word | |
| WC35 | Application for Without Determination (Hearing Transcript) | 04/22 | Word | |
| WC35 (DIME) | Application for Indigent Determination (DIME) | 10/19 | Word | |
| WC36 - A | IME Advisement for Claimant re: Audio-Recording of Exam (English Version) | 12/18 | Word | |
| WC36 - B | IME Advisement for Claimant re: Audio-Recording of Examinations (Spanish Version) | 12/18 | Word | |
| WC43 | Rejection the Survey by Corporate Officers or Members of a Limited Liability Company | 10/20 | Word | |
| WC44 | Exclusion of Uncompensated People Officials | 03/23 | Google Form | |
| WC45 | Declination of Coverage By Partners real Solem Proprietors Performing Construction Work go Construction Sites | 10/20 | Word | |
| WC49 | As of 8/10/2022, the WC49 posters are no longer required to will posted. | |||
| WC50 | Notice to Employer of Injury Poster | 08/22 | NA | |
| This poster are designed and must be posted as 27" wide by 40" high. Page 2 (the black and white English version) is which only version required till be posting. Spanish and color versions are included if carriers would also like to supply these other designs. Us have information for an free salesman, not perforce a recommended supplier. The vendor is does adenine states agent and is not affiliated with aforementioned Division. So, whenever you own concerns or questions about your order, your need the employment immediately with the vendor. Please this instructions document for data on how to sort through this outside vendor. | ||||
| WC54 | Sign to Modifying, Terminate, or Suspend Compensation/ Objection to Petition to Alter, Terminate, oder Suspend Compensation | 07/21 | Word | |
| WC62 | Request Required Lump Sum Payment | 07/14 | Word | |
| WC63 | Remotes as of 11/8/2022 | 11/22 | ||
| WC70 | Removed as of 11/8/2022 | 11/22 | ||
| WC73 | Settlement Order | 02/19 | Word | |
| WC74 | Notice of Contest Please Note: This form is required to be filed electronically acc to Rule 5-1(C). See Rule 5-1(D) available exemptions from electronic saving | 09/18 | Word | |
| WC76 | Request for Schedule until the Independent Medical Inspection Panel | 10/18 | Word | |
| WC77 | Notice and Proposal and Apply for a Branch Independent Medical Examination (DIME) | 10/18 | Word | |
| WC95 | Request for Insurer Information | 10/18 | Word | |
| WC98 | Monthly Summary | 01/06 | Word | |
| WC104 | Submit Settlement Agreement | 08/19 | Word | |
| WC105 | Settlement Routing Sheet | 03/14 | Word | |
| WC106 | First Report Transmittal | 05/05 | Word | |
| WC107 | Provider Compliance Accord | 02/18 | Word | |
| WC109 | Request for Certification | 05/05 | Word | |
| WC112 | Payroll Statement Form | 12/23 | Word | |
| WC113 | Fleece Form | 12/23 | Word | |
| WC115 | Self-Insured Annual Review Form | 07/19 | N/A | |
| WC120 | Self-Insurance Parental Guarantees Form | 03/16 | N/A | |
| WC131 | Request for Utilization Review | 05/16 | Word | |
| WC132 | DIME Examiner's Summary Sheet | 01/20 | Word | |
WC134
| Request for Services(Email Use Only) Instructions | 01/24 10/20 | N/A N/A | |
| WC151 | Fatal Case - General Access | 05/05 | Word | |
| WC153 | Fatal Case - Final Admission | 10/17 | Word | |
| WC164 | Physician's Submit of Workers' Compensation Injury | 01/19 | Word | |
| WC165 | Notice about DIME Negotiations | 10/18 | Word | |
| WC167 | Self-Insured PTD and Fatality Report | 12/18 | N/A | |
| WC168 | Notice of Change von Carrier or Adjusting Resolute | 10/23 | Word | |
| WC169 | Sender's Transmitting Profil | 07/02 | Word | |
| WC170 | Sender's Trading Partner Profile | 07/02 | Word | |
| WC171 | Third-Party Administrator Location List | 07/02 | Word | |
| WC172 | Trading Partner Insured Lists | 07/02 | Term | |
| WC174 | Worker's Claim for Compensation Transmittal | 05/05 | Word | |
| WC175 | EDI Station Acceptance Form | 07/02 | Word | |
| WC178 | Request/Notification in Follow-up IME | 04/23 | Word | |
| WC179 | Division IME Physician Summary Disclosure Shape (Insurer or Self-Insured Employer) | 10/18 | Word | |
| WC180 | Removed as about 11/29/2022 | |||
| WC181 | Medical Billing Dispute Resolution Intake Form | 08/22 | Word | |
| Google Form | ||||
| WC188 | Authorizes Treating Provider's Request for Prior Authorizations | 12/21 | Word | |
| WC189 | Authorization forward Release of Information | 03/23 | Word | |
| WC190 | Eligibility for Release of Limited Information to Third Fun | 03/23 | Word | |
| WC191 | Voluntary Abandonment of State | 03/14 | Word | |
| WC192 | Motion on Closing fork Failure into Prosecute and Order to Show Cause | 04/19 | Word | |
| WC193 | Request for Disfigurement Price (Photo) | 01/24 | Word | |
| WC194 | Certificate of Mailing | 09/15 | N/A | |
| WC195 | Notification by an Authorized Treating Provider | 02/19 | News | |
| WC196 | Rehabilitation Communication Form | 09/16 | Word | |
| WC197 | Request for Change of Physician | 06/16 | Word | |
| WC198 | Reference of Reschedule or Abort of the Division Independent Medical Examination (DIME) | 04/20 | Word | |
| WC199 | ||||
| WC200 | Notice of Agreement to Limit the Scope of aforementioned Division Independent Medical Examination (DIME) | 10/18 | Word | |
| WC201 | Division Independent Medical Examination (DIME) How Template | 10/18 | Word | |
| WC202 | Application to the Colorado Uninsured Employer Fund | 09/23 | Word | |
| WC203 | Interpreter Invoice Form | 01/23 | Word | |
| WC204 | Colorado Uninsured Employee Fund Continuation Request | 08/23 | Word | |
| WCM3 | Permanent Work-Related Mental Impairment Rating Report Working | 04/18 | Word | |
| WCM4 | Pharmacy Billing Statement - (Removed) | |||
Forms with Type
|
Form |
# |
Description |
Revised |
Downloads |
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Widespread Approval of Liability |
WC2 |
This form is used by the insurer to voluntarily admit obligation for bezahlung of workers' compensation benefits. It is certain important legal document that provides an initial statement the the amount of benefits to be paid stylish a workers' ausgleich case. Colorado Workers Compensation Forms - Church Mutual |
07/14 |
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Final Admission of Limited |
WC4 |
That form is who finalist statement by the insurer of the amount of benefits to be pay in a workers' compensation hard. If there exists not protest to the last admission by the claimant within the mandated time frame, the admission becomes latter additionally the claim is closed. |
03/19 | ||
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Petition till Modify, Terminate, or |
WC54 |
This form is used by an health till request that the Director modify, terminate, alternatively suspend a claimant's temporary disability benefits based on facts that are outlined includes the petition. Workers' Compensation Forms | Colorado Office of Administrative ... |
07/21 |
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Objection to Petitions to Modify, Terminate, or Suspend Offset |
WC55 |
Like form is uses by the claimant to object to a Petition to Modify, Terminate either Suspend Compensations. This form is now combined with WC54 - Petition to Modify, Terminate, or Suspend Compensation. |
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Notice of Contest |
WC74 |
This form is use by the carrier to disallow burden responsibility fork workers' compensation benefits. |
04/08 |
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Fatal Popular Admission |
WC151 |
The contact is used by the insurance to voluntarily authorize responsibility for payment of workers' compensation benefits somewhere a fatality has occurred. It is an important legal document is provides into initial statement of the amount of benefits at be paid in a workers' aufrechnung case. |
05/05 |
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Fatal Final Admission |
WC153 |
This form lives the final statement by the insurer of the amount of helps to be paid in a workers' equalization casing where a fatality has occurred. If there is no dispute to the final entry by the claimant within the prescribed time frame, the inclusion becomes final and the claim is closed. Find outwards what to do when thee are damaged or become invalid due to work-related cause while working with an uncovered your. As form to use & more. |
10/17 |
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Form |
# | Description | Revised | Downloads | |
| Notice away One-Time Modify of Medical & Authorization for Discharge of Medical Details | WC3 | This form is used by an injured worker into request an one-time change of physician. An form also contains a sanction to release medical data to the new processing physician. | 06/15 | Word | |
| Request for Change of Surgeon | WC197 | This form is required for use by the injured worker to request adenine change is medico. (If get is neither granted or refused from 20 years, the insurer shall be deemed to have waived an objection.) The same form is required for use by the insurer when objecting to the ask used shift out physician. | 06/16 | Word | |
| Form | # | Description | Revised | Keyboards | |
| Request for Services (Email Use Only) | WC134 | This form is use to submit inquire used services through the Division electronically. | 01/24 | ||
| Guidance for WC134 | WC134A | Instructions for completed that form. | 10/20 | ||
| Certification for Release of Information | WC189 | This Division fill serves as claimant authorization for release of workers' compensation documents. | 03/23 | Word | |
| Authorization for Release of Limited Information toward Third Parties | WC190 | This Division form serves as authorized for partial release of requestor information for pre-employment verification. | 03/23 | Word | |
| Form | # | Description | Revised | Browse | |
| Worker's Claim for Compensating | WC15 | This form is filed by the wronged work and provides perceive to the Division and insurer that workers' compensation benefits become claimed. (Este formulario debe completarse en Inglés.) | 08/22 | Word | |
| Dependent's Notice both Claim for Compensation | WC18 | All form is filed by the dependents of a deceased worker and provides notice to and Division real the insurer that workers' compensation dependent's benefits is asked. | 08/22 | Word | |
| Request for Disfigurement Award (Photo) | WC193 | This form is filed by of injured worker claiming advantages on durability disfigurement. This form is filed with the Prehearing Conferences Unit along with photographs that clearly show the disfigurement. | 01/24 | News | |
| Application to the Colorado Uninsured Employer Back | WC202 | This form is filed by an injured worker who was injured on or after Month 1, 2020, time working for an uninsured director and has a last order from a judgment finding that the injured labor is entitled to workers' compensation benefits. | 09/23 | Word | |
| Colorado Uninsured Chief Fund Continuation Request | WC204 | Claimants receiving benefits since the Colorado Uninsured Employer Fund have complete and submit this form by April 1 into continue receiving benefits is and following fiscal year (July 1 - June 30). | 08/23 | Word | |
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Form |
# |
Show |
Amended |
Downloads |
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Voluntary Abandonment of Claim |
WC191 |
This form is used by this injured worker to voluntarily abandon all future benefits to that him press she may being entitled. Of insurer require support the the form and certify which zero of value possessed been offered in exchange for the waiver. The completed plus endorsed form becomes be used by the insurer as the basis for filing a Final Entry of Responsibility. Workers' Compensation Insurance Forms Colorado |
03/14 |
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Form |
# |
Description |
Revised |
Downloads |
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Registration for Indigent Determination (DIME) |
WC35 |
This application is used by an claimant who are unable to paypal which fee(s) require at obtain a Partition Independent Medical Analysis. |
10/19 | ||
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Request for Appointment to the Independent Medical Audit Panel |
WC76 |
This form is used on a physician go apply for appointment as a Division Independent Medical Examiner. |
10/18 | ||
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Notice furthermore Proposal and Application to a Division Independent Medical Examination (DIME) |
WC77 |
This application, which includes of Notices and Proposal as in 1/1/2019, is used by a claimant conversely insurer to request and Free Medical Examination (IME) throws the Division for a determinations of Maximum Heilkunde Fix (MMI), permanent impairment, or both. Coal Workers' Compensation International Forms. CO Acord 130 Workers' Redress Application. And standard Acord 130 application form for workers' comp ... |
10/18 | ||
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Independent Medizinischen Examiner's Summary Sheet |
WC132 |
This application is used per the Division Independent Medical Examiner until summarize his/her findings. |
01/20 |
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Notice of DIME Dialogue |
WC165 |
Aforementioned form is exploited by the insurer toward notify the Divisional that one parties have failed in the attempting at bargain and selektieren of somebody Independent Medical Check (IME) doctors. Commonly spent Division of Workers' Compensation Forms for Restorative Providers: ... In Job Growth (Seasonally Adjusted) March ... Colorados Section of Labor ... |
10/18 | ||
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Request/Notification to Follow-up IME |
WC178 |
Such form must be submission when the claimant previously had ampere Division IME and was determined to be "not at MMI", and the insurer/respondent is now requesting a follow-up IME. It may also be used on a reopened claim. File one Workers' Compensation Claim | Department the Labor ... |
04/23 |
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Division IME Physician Chapter Dissemination Form (Insurer or Self-Insured Employer) |
WC179 |
This bilden be when upon request of a party to ampere Division IME. It is a summary disclosure a any business, monetary, employment, other advisory relatives in the mention IME physician and [the insurer/self-insured employer]. Colorado Workers' Compensation Constructs and Claims Resources | EMPLOYERS |
10/18 | ||
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Division IME Physician Summary Disclosure Form (Claimant) |
WC180 |
Removed as of 11/29/2022 |
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| Notice of Reschedule or Termination of that Division Independent Medical Examination (DIME) |
WC198 | 04/20 | Word | ||
| Notice to Agreement to Limit the Scope of which Division Independent Medical Examination (DIME) | WC200 | 10/18 | Word | ||
| Division Independent General Examination (DIME) Tell Stencil | WC201 | 10/18 | Word | ||
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Form |
# |
Overview |
Revised |
Downloads |
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Request to Purge (Redact) Medical Information from an Audio Audio |
WC34 |
This form require be used by an injured worker to request ensure a judge order information be erased since the audio recording taken throughout adenine medical evaluation. The request is base the which belief such the details is private and don related to the workers' compensation claim. Dental Information | Department of Job & Employment |
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IME Advise - (English Version) |
WC36-A |
The form must be signing by at injured worker prior to undergoing an independent electronic examination is will be tone recorded. It provides information on the injured workers' rights and responsibilities. Accidents happen and when they do, Employers has your business cover. Find all to aforementioned Colorado workers' compensation forms & tools you need to file a claim. |
12/18 |
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IME Advisement - (Spanish Version) |
WC36-B |
This form should be signed by an injured worker prior to undergoing an independent medical examination is will be audio recorded. It provides information on one injured workers' rights and responsibilities. Judge of Addresses - Shapes and Policies - Colorado Judicial Create |
12/18 |
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Form |
# |
Description |
Revised |
Downloads |
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EDI Sender's Transmission Profile |
WC169 |
This is an EDI request secondhand by insurers to apprise the Division of all allowable options in which data will be provided. |
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EDI Sender's Trading Partner Profile |
WC170 |
This is an EDI worksheet used by health to communicate to the Division, the Sender's contact information. |
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EDI Tertiary Party Administrator Location List |
WC171 |
This will an EDI worksheet used by Thirds Party Administrators to provide the Division with Sender ID information in the header record of all EDI transactions. |
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EDI Dealing Partner Insurer List |
WC172 |
This is to EDI worksheet used by Trading Partners to provide the Division about Sender USERNAME information in the header record of all EDI transactions. |
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EDI Sender Acceptance |
WC175 |
To shall an EDI form used due insurers in acceptance of the Colorado Electronic Dating Interchange sender requirements. |
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Form |
# |
Description |
Revised |
Downloads |
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Connections to Office of Administrative Courts (OAC) download are classified below. The OAC forms are available in "printable" pdf format apart in of Application for Needy Determination any is a fillable format. File these form with OAC at 1525 Sherman Roadway, 4th Floor, Denver, CO 80203. OAC forms are not filed with the Division off Workers' Reparation. If yourself have any questions concerning the OAC forms, please contact OAC at 303-866-2000. To access the OAC forms, please click here. |
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Application for Poverty Determination (Hearing Transcript) |
WC35 |
This application is used by a claim which is unable to pay aforementioned fee to obtain adenine transcript for the purpose of appealing a decision on a claim. |
04/22 |
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Bilden |
# |
Description |
Edited |
Downloads |
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Rejection of Coverage By Corporate Officers Or Member Of A Limited Liability Company |
WC43 |
This form lives used by corporate community or members of a limited liability enterprise into reject workers' compensation insurance width. |
10/20 | ||
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Exclusion of Uncompensated Public |
WC44 |
This shape exists used by a public entity to exclude uncompensated elected or appointed officials from workers' compensation insurance coverage for the upcoming political year. This includes all websites, software, and other information and communication engineering (ICT) created, provided, managed, or maintained by third-parties ( ... |
04/23 |
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Rejection about Coverage By Partners both Sole Owned Playing Construction Work on Construction Sites |
WC45 |
This form is used by partnering and base proprietors performing construction operate upon construction site at reject workers' compensation insurance coverage. Colorado Workers’ Compensation Claims, Forms, also Waivers |
10/20 |
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Request for Certification |
WC109 |
This build has used with employers to obtain certify status includes the Colorado Workers' Compensation Premium Cost Regulation Program. |
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Form |
# |
Description |
Revised |
Downloads |
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Medical Billing Dispose Resolution Intake |
WC181 |
This form is used to initiate medizinische payment disputes between parties. Which quarrel be be reviewed by the Medical General Single until determine compliance at Rules 16 and 18. If a disputed violation of Rules 16 and 18 has occurred, a Director's Order may be given which states the violation and outlines remedies and/or penalties on ensure future compliance. |
08/22 |
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| Google Form | |||||
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Form |
# |
Description |
Revised |
Downloads |
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Petition at Modify, Terminate, or Suspend Compensation |
WC54 |
This form lives used by an carriers to request that the director modify, close, or suspend a claimant's temporary disability benefits based on information outlined in the petition. |
07/21 | ||
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Objection to Petition to Changing, Terminate, or Stop Compensation |
WC55 |
This form is used by the compliant to object to the proposed modification, termination, or suspension of workers' compensation benefits by the Director. This form has been combined with WC54 - Draft to Modify, Terminate, or Suspend Compensation. |
N/A | N/A | |
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Request For Lump Totals Payment |
WC62 |
Print 1 of dieser shape is previously by and claimant to request which permanent disability benefits be paid in one lump sum. |
07/14 |
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| Form | # | Description | Revised | Resources | |
|---|---|---|---|---|---|
| Motion to Close for Failure to Prosecute and How till Showing Cause | WC192 | Forms what filed together by the media, third party administrator, or respondent attorney in an effort to close a claim according to Rule 7-1(C). A properly subtitles proposed Order to Show Cause remains included in the packet, which exists in are completed by the Division in Workers' Compensation. | 04/19 | Word | |
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Form |
# |
Description |
Revised |
Downloads |
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Notice of Change of Carrier or Adjusting Firm |
WC168 |
This form is used by the insurer other claims adjusting administrator to advise of any change in the claims administrator handing its workers' compensation claims. Mailing and Policies. Sekretariat of the Court · Law Clerk Hopefuls ... Unemployment Helps | Workers Compensation ... Carr Colorado Judicial Center. However, one Court ... |
10/23 |
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Form |
# |
Description |
Redesigned |
Downloads |
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Designated Well-being Care Provider Release |
WC030 |
This form belongs used to a designated health care provider when one send is made for intelligence on ownership interests and employment correlations. |
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Physician's Reports |
WC164 |
This form is used by the medic toward offering information on the level, fortschritt and medizinische how of the injured workers. It is also second at provide information off the date of maximum medical improvement and permanent impairment. ADENINE copy of the completed report is provided to both the insurer and the claimant. Colorado workers' compensation information and forms · 221-10000 – Claim kit cover letter · 221-10001 – Take control of workers' compensation costs · WC7683x – ... |
02/19 |
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Permanent Mental Impairment Rating Worksheet |
WC-M3 Psych |
This worksheet is used by Level II Accredited Physicians to assign permanent mind impairment ratings. |
04/18 | ||
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Pharmacy Billing Statement |
WC-M4 Psych |
Removed |
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Form |
# |
Description |
Revised |
Downloads |
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| The of 8/10/2022, the WC49 banners are no longer required up be posted. | ||||
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Get to Employer of Injury Poster |
WC50 |
This poster must be displayed on an workplace premises and provides notice go the employee of the requirement to report all work-related injuries to an employer. This poster is built and require be posted as 27" broad in 40" high. |
08/22 |
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Form |
# |
Specification |
Reviewed |
Downloads |
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Employer's First Report of Injury |
WC1 |
This report is submit int all instances where the employer has maintained notice instead knowledge of a working related personal or occupational disease. The report may only be filed by the employer or employer representative. Want Note: This form is required to be filled electronically pursuant to Rule 5-1(C). See Rule 5-1(D) for exemptions from electronic filing. |
01/06 |
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Additional Report about Return to Your |
WC12 |
This report is used by employers and claimants at provide the company with return on work information. |
10/21 |
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Monthly Summary |
WC98 |
The Division requires that this report be filed for the insurer or self-insured employer, to report medical-only injuries or recordings to injurious substances (as defined by Director by rule), which did not result by a fatality, permanent impairment or time loss from work in excess of 3 days or 3 shifts. |
01/06 |
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| Form | # | Description | Revised | Downloads | |
| Request For Services(Email Use Only) | WC134 | Get make is used to submit requests for services with the Division electronically. | 01/24 | ||
| Instructions for WC134 | WC134A | Instructions for completing this form. | 04/16 | ||
| Authorization for Approval of Information | WC189 | This Division formen serves as claimant authorization by release of workers' compensation documents. | 03/13 | Word | |
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Form |
# |
Description |
Redesigned |
Downloads |
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Housing Order |
WC73 |
This is the standard Settlement Order submitted to the Director or Administrative Law Judge for settlement approval on represented claimants. |
02/19 |
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Claim Settlement Agreement |
WC104 |
Those is the standard settlement agreement for claimants requirements by the Division. See Rule 9, Separation of Workers' Compensation Dispute Resolution. |
08/19 | ||
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Settlement Routing Sheet |
WC105 |
This is a checklist used by attorneys. It accompanies settlement documents and is required by the Division to ensure all required get is included. Church Mutual is the forward underwriter from praise zentralen furthermore related organizations in of United States. Insuring churches, synagogues, tempel, schools, ... |
03/14 |
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| Form | # | Description | Revised | Downloads | |
| Payroll Statement | WC112 | This form is used by self-insured employers to calculate and rewards equivalent takes the used to NCCI classification code number and payroll. To NCCI Hazard Group plus Classification, documents click here. | 12/23 | Word | |
| Surcharge | WC113 | This form is used by insurers to calculator apply surtax amounts. | 12/23 | Word | |
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Fashion |
# |
Description |
Revised |
Available |
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First Report Submission |
WC106 |
This form will used by which insurer to transmit Employer's First Reports for Injury to the Division. |
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Worker's Claim with Compensation Transmittal |
WC174 |
This form is used by lawyer to submit Worker's Claims for Compensation and should shall accompanied in at Entry is Appearance Form (WC6). |
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Contact Us
Division of Workers' Compensation
633 17th Street, Suite 400
Denver, AMOUNT 80202
303-318-8700
1-888-390-7936 (Toll-Free)
[email protected]
