Colorado > Workers Comp
Application For Lump Sum WC62 - Colorado
| Application For Lump Sum Form. This is a Colorado form and can be used in Workers Comp . |
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COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT DIVISION OF WORKERS' COMPENSATION REQUEST FOR LUMP SUM PAYMENT (Permanent Partial, Permanent Total and Dependents' Benefits) Claimant Date of Injury Insurance Carrier Insurance Carrier/TPA Address Street CHECK THE APPROPRIATE BOX: W.C. # Employer Insurance Carrier Claim # City State Zip Code I am represented and request a lump sum payment* I am not represented and request a lump sum payment (to be calculated and ordered by the Division of Workers' Compensation.) * the lump sum, less discount, will be calculated and paid by the insurance carrier FAILURE TO SIGN THE APPLICATION MAY DELAY PROCESSING OF YOUR REQUEST. NOTE: A lump sum payment cannot be granted until SIX (6) MONTHS have elapsed from the date of injury or death, and there has been a final award of permanent benefits. The total of all lump sums may not exceed $60,000 per claim. 1. Name of applicant: Address Street Phone #: City ( ) State Zip Code 2. 3. 4. 5. 6. 7. Date of applicant's birth: If applicant is other than claimant, state family relationship: The disability or death benefit award is the result of a: Date of disability or death benefit award: Month Day Year Final Admission Final Order Amount requested $ Monthly Amount Monthly Amount $ $ Applicant is presently: Receiving Social Security Benefits Receiving pension benefits or other income Check the box that applies: I accept the amount of permanent partial or permanent total disability benefits if so awarded. I understand that in accordance with section 8-43-406 of the Colorado Workers' Compensation Act, a four percent per annum discount is subtracted from the total award. I accept the award of death benefits. I understand that in accordance with section 8-43-406 of the Colorado Workers' Compensation Act, a four percent per annum discount is subtracted from the total award. Dated this day day of month , year . Applicant's Signature COMPLETE, SIGN AND DELIVER OR MAIL ONE COPY OF THIS FORM TO THE INSURANCE CARRIER HANDLING YOUR CLAIM AND ONE COPY TO THE DIVISION OF WORKERS' COMPENSATION WC62 Rev. 09/12 Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT DIVISION OF WORKERS' COMPENSATION LUMP SUM CALCULATION AND PROOF OF PAYMENT Claimant: WC#: Insurance Adjuster: Please complete this form within 10 business days of the mailing date of the claimant's request for a lump sum payment. A copy should be sent to the claimant and attorney if represented. Check the applicable box: The insurance carrier has calculated and paid a lump sum and is confirming payment (Complete entire form) The insurance carrier is submitting figures to the Division to calculate a lump sum (Complete Parts A, C & D) The insurance carrier objects to the payment of a lump sum based on the following: Type of Award Check one: Part A: Calculation PPD (permanent partial disability) PTD (permanent total disability) Fatal (dependant's benefits) 1. Total award for permanent partial disability (PPD), if applicable: 2. Compensation rate prior to any offset(s) for PPD, PTD, or Fatal benefits: 3. If there is an offset, what is the weekly payment rate after the offset? No 4. Has a previous lump sum been paid? If so, what is the aggregate of all lump sums awarded? Provide date(s) of payment Yes $ $ $ $/ Yes / If so, what is the amount? 5. Is there an overpayment to be credited? No $$$ 6. Amount of PPD paid to date, if applicable: (Includes previous lump sums, discounts & overpayments in # 4 & # 5) / / Permanent partial disability is paid through (date): 7. PPD balance due: (Total award for PPD in # 1 less PPD paid to date in # 6 equals PPD balance due) Part B: Confirmation of Payment 1. Date of Payment: Amount of payment: $ $ 2. Lump sum discount applied (attach all print-outs of the discount calculation) 3. Is there a PPD balance remaining? Part C: Adjuster Information Adjuster: Phone #: Fax #: No Yes If yes, amount: $ ( ( ) ) Part D: Certificate of Mailing: Copies of this document were placed in the U.S. mail or delivered to the following parties this day of day month , year by: Insurance Adjuster or Representative List names and addresses of all persons copied: Claimant: Claimant Attorney: Respondent Attorney: Division of Workers' Compensation, 633 17th St., Suite 400, Denver, CO 80202-3626 Notice to Applicant: If you object to this response, notify the Division of Workers' Compensation in writing of your objection within 10 (ten) days from the certificate of mailing date. Mail this objection to the Division of Workers' Compensation, 633 17th St., Suite 400, Denver, CO 80202-3626. Block # Adj. Code WC62 Rev. 09/12 Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com
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