This form is used by the insurer to voluntarily admit responsibility for payment of workers' compensation benefits. It is an important legal document that provides an initial statement of the amount of benefits to be paid in a workers' compensation case.
Final Admission of Liability
This form is the final statement by the insurer of the amount of benefits to be paid in a workers' compensation case. If there is no objection to the final admission by the claimant within the prescribed time frame, the admission becomes final and the claim is closed.
Petition to Modify, Terminate, or
Suspend Compensation
This form is used by an insurer to request that the Director modify, terminate, or suspend a claimant's temporary disability benefits based on facts that are outlined in the petition.
Objection to Petition to Modify, Terminate, or Suspend Compensation
This form is used by the claimant to object to a Petition to Modify, Terminate or Suspend Compensation. This form is now combined with WC54 - Petition to Modify, Terminate, or Suspend Compensation.
Notice of Contest
This form is used by the insurer to deny liability responsibility for workers' compensation benefits.
Please Note: This form is required to be filed electronically pursuant to Rule 5-1(C). See Rule 5-1(D) for exemptions from electronic filing.
Fatal General Admission
This form is used by the insurer to voluntarily admit responsibility for payment of workers' compensation benefits where a fatality has occurred. It is an important legal document that provides an initial statement of the amount of benefits to be paid in a workers' compensation case.
Fatal Final Admission
This form is the final statement by the insurer of the amount of benefits to be paid in a workers' compensation case where a fatality has occurred. If there is no objection to the final admission by the claimant within the prescribed time frame, the admission becomes final and the claim is closed.
Change of PhysicianForm
Claimant Authorization for Release of Information| Form | # | Description | Revised | Downloads | |
| Request for Services (Email Use Only) | WC134 | This form is used to submit requests for services through the Division electronically. | 01/24 | ||
| Instructions for WC134 | WC134A | Instructions for completing this form. | 10/20 | ||
| Authorization for Release of Information | WC189 | This Division form serves as claimant authorization for release of workers' compensation documents. | 03/23 | Word | |
| Authorization for Release of Limited Information to Third Parties | WC190 | This Division form serves as authorization for partial release of claimant information for pre-employment verification. | 03/23 | Word | |
| Form | # | Description | Revised | Downloads | |
| Worker's Claim for Compensation | WC15 | This form is filed by the injured worker and provides notice to the Division and insurer that workers' compensation benefits are claimed. (Este formulario debe completarse en Inglés.) | 08/22 | Word | |
| Dependent's Notice and Claim for Compensation | WC18 | This form is filed by the dependents of a deceased worker and provides notice to the Division and the insurer that workers' compensation dependent's benefits are claimed. | 08/22 | Word | |
| Request for Disfigurement Award (Photo) | WC193 | This form is filed by the injured worker claiming benefits for permanent disfigurement. This form is filed with the Prehearing Conference Unit along with photographs that clearly show the disfigurement. | 01/24 | Word | |
| Application to the Colorado Uninsured Employer Fund | WC202 | This form is filed by an injured worker who was injured on or after January 1, 2020, while working for an uninsured employer and has a final order from a judge finding that the injured worker is entitled to workers' compensation benefits. | 09/23 | Word | |
| Colorado Uninsured Employer Fund Continuation Request | WC204 | Claimants receiving benefits from the Colorado Uninsured Employer Fund must complete and submit this form by April 1 to continue receiving benefits in the following fiscal year (July 1 - June 30). | 08/23 | Word | |
Form
Description
Revised
Downloads
Voluntary Abandonment of Claim
This form is used by the injured worker to voluntarily abandon all future benefits to which he or she may be entitled. The insurer must endorse the the form and certify that nothing of value has been offered in exchange for the waiver. The completed and endorsed form will be used by the insurer as the basis for filing a Final Admission of Liability.
Division Independent Medical Examinations| Form | # | Description | Revised | Downloads | |
| Application for Indigent Determination (DIME) | WC35 | This application is used by a claimant who is unable to pay the fee(s) required to obtain a Division Independent Medical Examination. | 10/19 | Word | |
| Request for Appointment to the Independent Medical Examination Panel | WC76 | This form is used by a physician to apply for appointment as a Division Independent Medical Examiner. | 07/24 | Digital Form | |
| Notice and Proposal and Application for a Division Independent Medical Examination (DIME) | WC77 | This application, which includes the Notice and Proposal as of 1/1/2019, is used by a claimant or insurer to request and Independent Medical Examination (IME) through the Division for a determination of Maximum Medical Improvement (MMI), permanent impairment, or both. | 10/18 | Word | |
| Independent Medical Examiner's Summary Sheet | WC132 | This form is used by the Division Independent Medical Examiner to summarize his/her findings. | 01/20 | Word | |
| Notice of DIME Negotiations | WC165 | This form is used by the insurer to notify the Division that the parties have failed in the attempt to negotiate the selection of an Independent Medical Examination (IME) physician. | 10/18 | Word | |
| Request/Notification for Follow-up IME | WC178 | This form must be submitted when the claimant previously had a 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. | 04/23 | Word | |
| Division IME Physician Summary Disclosure Form (Insurer or Self-Insured Employer) | WC179 | This form is provided upon request of a party to a Division IME. It is a summary disclosure of any business, financial, employment, or advisory relationship between the listed IME physician and [the insurer/self-insured employer]. | 10/18 | Word | |
| Division IME Physician Summary Disclosure Form (Claimant) | WC180 | Removed as of 11/29/2022 | |||
| Notice of Reschedule or Termination of the Division Independent Medical Examination (DIME) | WC198 | 04/20 | Word | ||
| Notice of Agreement to Limit the Scope of the Division Independent Medical Examination (DIME) | WC200 | 10/18 | Word | ||
| Division Independent Medical Examination (DIME) Report Template | WC201 | 10/18 | Word | ||
Form
Description
Revised
Downloads
Request to Erase (Redact) Medical Information from an Audio Recording
This form must be used by an injured worker to request that a judge order information be erased from the audio recording taken during a medical evaluation. The request is based on the belief that the information is private and not related to the workers' compensation claim.
IME Advisement - (English Version)
This form must be signed by an injured worker prior to undergoing an independent medical examination that will be audio recorded. It provides information on the injured workers' rights and responsibilities.
IME Advisement - (Spanish Version)
This form must be signed by an injured worker prior to undergoing an independent medical examination that will be audio recorded. It provides information on the injured workers' rights and responsibilities.
Electronic Data Interchange (EDI)Form
Description
Revised
Downloads
EDI Sender's Transmission Profile
This is an EDI form used by insurers to inform the Division of all allowable options in which data will be provided.
EDI Sender's Trading Partner Profile
This is an EDI worksheet used by insurers to communicate to the Division, the Sender's contact information.
EDI Third Party Administrator Location List
This is an EDI worksheet used by Third Party Administrators to provide the Division with Sender ID information in the header record of all EDI transactions.
EDI Trading Partner Insurer List
This is an EDI worksheet used by Trading Partners to provide the Division with Sender ID information in the header record of all EDI transactions.
EDI Sender Acceptance
This is an EDI form used by insurers in acceptance of the Colorado Electronic Data Interchange sender requirements.
Hearings and TranscriptsForm
Description
Revised
Downloads
Links to Office of Administrative Courts (OAC) forms are listed below. The OAC forms are available in "printable" pdf format except for the Application for Indigent Determination which is a fillable format. File these forms with OAC at 1525 Sherman Street, 4th Floor, Denver, CO 80203. OAC forms are not filed with the Division of Workers' Compensation. If you have any questions concerning the OAC forms, please contact OAC at 303-866-2000. To access the OAC forms, please click here.
Application for Indigent Determination (Hearing Transcript)
This application is used by a claimant who is unable to pay the fee to obtain a transcript for the purpose of appealing a decision on a claim.
Insurance Exemptions and Certifications Medical Billing DisputesForm
Description
Revised
Downloads
Medical Billing Dispute Resolution Intake
This form is used to initiate medical payment disputes between parties. The dispute will be reviewed by the Medical Policy Unit to determine compliance with 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 to ensure future compliance.
Medical Utilization ReviewForm
Description
Revised
Downloads
Request for Utilization Review
This form is used by claimants and insurers to request a review of medical treatment that has been provided to a claimant.
Modification and Disbursement of BenefitsForm
Description
Revised
Downloads
Petition to Reopen
This form is used by the claimant to request that a workers' compensation claim be reopened. (Removed as of 7/1/2021. Claimants should utilize the Application for Hearing provided by the OAC.)
Petition to Modify, Terminate, or Suspend Compensation
This form is used by an insurer to request that the director modify, terminate, or suspend a claimant's temporary disability benefits based on information outlined in the petition.
Objection to Petition to Modify, Terminate, or Suspend Compensation
This form is used by the claimant to object to the proposed modification, termination, or suspension of workers' compensation benefits by the Director. This form has been combined with WC54 - Petition to Modify, Terminate, or Suspend Compensation.
Request For Lump Sum Payment
Page 1 of this form is used by the claimant to request that permanent disability benefits be paid in a lump sum.
Page 2 of the form is used by the insurer to provide proof to the Division of accurate calculation and timely payment of benefits to all parties in a claim in which a permanent partial disability lump sum is requested.
Page 3 is used by the insurer to provide proof to the Division of accurate calculation and timely payment of benefits to all parties in a permanent total disability or fatal claim.
| Form | # | Description | Revised | Downloads | |
|---|---|---|---|---|---|
| Motion to Close for Failure to Prosecute and Order to Show Cause | WC192 | Forms are filed together by the carrier, third party administrator, or respondent attorney in an effort to close a claim according to Rule 7-1(C). A properly captioned proposed Order to Show Cause is included in the packet, which is to be completed by the Division of Workers' Compensation. | 04/19 | Word | |
Form
Description
Revised
Downloads
Notice of Change of Carrier or Adjusting Firm
This form is used by the insurer or claims adjusting administrator to advise of any change in the claims administrator handling its workers' compensation claims.
Physician Reports/Worksheets/DisclosureForm
Description
Revised
Downloads
Designated Health Care Provider Disclosure
This form is used by a designated health care provider when a request is made for information on ownership interests and employment relationships.
This form is used by the physician to provide information on the status, progress and medical treatment of the injured worker. It is also used to provide information on the date of maximum medical improvement and permanent impairment. A copy of the completed report is provided to both the insurer and the claimant.
Permanent Mental Impairment Rating Worksheet
This worksheet is used by Level II Accredited Physicians to assign permanent mental impairment ratings.
Pharmacy Billing Statement
Form
Description
Revised
Downloads
Workers' Compensation Act Poster
This poster must be displayed on the workplace premises and provides information on possible workers' compensation entitlements and insurance coverage. The poster is a sample of the text only in English.
Workers' Compensation Act Poster
The poster is a sample of the text only in Spanish.
Notice to Employer of Injury Poster
This poster must be displayed on the workplace premises and provides notice to the employee of the requirement to report all work-related injuries to the employer.
This poster is designed and must be posted as 27" wide by 40" high.
Page 2 (the black and white English version) is the only version required to be posted. Spanish and color versions are included if carriers would also like to supply these other designs.
We have information for an available vendor, not necessarily a recommended vendor. The vendor is not a state agency and is not affiliated with the Division. So, if you have concerns or questions about your order, you need to work directly with the vendor. Visit this instructions document for information on how to order through this outside vendor.