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Form # |
Form Title |
Formats |
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WC1 |
Employer's First Report of Injury |
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WC2 |
General Admission of Liability |
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WC3 |
Notice of One-Time Change of Physician & |
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WC4 |
Final Admission of Liability |
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WC6 |
Entry of Appearance |
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WC12 |
Supplemental Report of Return to Work |
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WC15 |
Workers' Claim for Compensation |
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WC18 |
Dependent's Notice and Claim for Compensation |
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WC25 |
Final Payment Notice |
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WC30 |
Designated Health Care Provider Disclosure Form |
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WC34 |
Request to Erase (Redact) Medical Information from an Audio Recording |
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WC35 |
Application for Indigent Determination (Hearing Transcript) |
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WC35 (IME) |
Application for Indigent Determination (IME) |
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WC36 - A |
IME Advisement for Claimant re: Audio-Recording of Exam (English Version) |
N/A |
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| WC36 - B | IME Advisement for Claimant re: Audio-Recording of Exam (Spanish Version) | N/A | MS Word |
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WC37 |
Petition to Reopen |
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WC43 |
Rejection of Coverage by Corporate Officers or Members of a Limited Liability Company |
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WC44 |
Exclusion of Uncompensated Public Officials |
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WC45 |
Rejection of Coverage By Partners and Sole Proprietors Performing Construction Work on Construction Sites |
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WC49 - A |
Workers Compensation Act Poster (English Version) |
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| WC49 - B | Workers Compensation Act Poster (Spanish Version) | MS Word | |
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WC50 |
Notice to Employer of Injury Poster |
N/A |
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WC54 |
Petition to Modify, Terminate, or Suspend Compensation |
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WC55 |
Objection to Petition to Modify, Terminate, or Suspend Compensation |
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WC62 |
Request For Lump Sum Payment |
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WC63 |
Request for Offset of Liability to Subsequent Injury Fund |
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WC70 |
Application for Admission to the Colorado Major Medical Insurance Fund |
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WC73 |
Settlement Order (Represented Claimant) |
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WC74 |
Notice of Contest |
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WC76 |
Request for Appointment to the Independent Medical Examination Panel |
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WC77 |
Application for a Division Independent Medical Examination (IME) |
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| WC78 | Application for an 18 Month Division Independent Medical Examination (IME) | MS Word | |
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WC98 |
Monthly Summary |
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WC102 |
Pro Se Settlement Order (Unrepresented Claimant) |
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WC103 |
Settlement Agreement - Pro Se (Unrepresented) Claimant |
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WC104 |
Settlement Agreement - Represented Claimant |
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WC105 |
Settlement Routing Sheet |
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WC106 |
First Report Transmittal |
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WC109 |
Request for Certification |
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WC112 |
Payroll Statement Form |
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WC113 |
Surcharge Form |
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WC131 |
Request for Utilization Review |
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WC132 |
IME Examiner's Summary Sheet |
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WC146 |
Notice and Proposal to Select an Independent Medical Examiner |
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WC151 |
Fatal Case - General Admission |
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WC153 |
Fatal Case - Final Admission |
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WC164 |
Physician's Report of Workers' Compensation Injury |
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WC165 |
Notice of Failed IME Negotiation |
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WC168 |
Notice of Change of Carrier or Adjusting Firm |
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WC169 |
Sender's Transmission Profile |
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WC170 |
Sender's Trading Partner Profile |
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WC171 |
Third Party Administrator Location List |
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WC172 |
Trading Partner Insurer List |
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WC174 |
Workers' Claim for Compensation Transmittal |
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WC175 |
EDI Sender Acceptance Form |
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WC178 |
Request/Notification for Follow-up IME |
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| WC179 |
Division IME Physician Summary Disclosure Form (Insurer or Self-Insured Employer) |
N/A | MS Word |
| WC180 | Division IME Physician Summary Disclosure Form (Claimant) | N/A | MS Word |
| WCM3 | Permanent Work-Related Mental Impairment Rating Report Worksheet | MS Word | |
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WCM4 |
Pharmacy Billing Statement |
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