Colorado > Workers Comp
Fatal Case-Final Admission WC153 - Colorado
| Fatal Case-Final Admission Form. This is a Colorado form and can be used in Workers Comp . |
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FATAL CASE - FINAL ADMISSION Workers Compensation (WC) # Carrier Claim # Deceaseds Name Average Weekly Wage Deceaseds Social Security # Date of Death Date of Injury Weekly Compensation Rate Insurance Carrier Employer 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, this case will automatically close. If you disagree with the benefits admitted or not admitted you must do the following: 1. Within 30 days, write a letter to the Division of Workers Compensation, 1515 Arapahoe St., Denver, CO 80202-2117 with a copy to the insurance carrier or self-insured employer stating that you object to this admission. 2. Within the same 30 days, file an Application for Hearing on any disputed issues with the Division of Administrative Hearings at 1120 Lincoln St., 14th Floor, Denver, CO 80203 (on the western slope, mail to 222 South 6th, #414, Grand Junction, CO 81501.) See page 2 for other important notices. Liability is admitted for the following benefits: Medical Benefits Safety Rule Violation Funeral Expenses $ ___________________ Offset (Attach Calculation) Complete the following for each known dependent: (Attach additional pages, if needed) Attending School Whole or Partial Name Birth Date Yes or No Relationship Dependency(W or P) If no dependents, has payment been made to the Subsequent Injury Fund (SIF)? Yes No Remarks: (attach additional pages, if needed) BENEFIT HISTORY Dependents benefits (past and present) are admitted for the following: Name Time Periods Weeks Rate per Week Totals __________________________________________ __________through _________ = ______ x $ ____________ = $______________ __________________________________________ __________through _________ = ______ x $ ____________ = $______________ __________________________________________ __________through _________ = ______ x $ ____________ = $______________ __________________________________________ __________through _________ = ______ x $ ____________ = $______________ __________________________________________ __________through _________ = ______ x $ ____________ = $______________ The above time periods include the dates specified. Amount of Interest Paid $ __________________________ Amount of Penalties Paid $ __________________________ (Attach additional pages, if needed) 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 , . Dependent(s): Dependents Attorney(s): Employer: Carriers Attorney: Other: Division of Workers Compensation,1515 Ar apahoe Street, Denver, CO 80202-2117 By Block # Adj. Code WC153 Rev 8/03 Page 1 of 2 <<<<<<<<<********>>>>>>>>>>>>> 2 (The top portion of this side may be used for mailing address) FATAL CASE - FINAL ADMISSION IMPORTANT: SEE NOTICE TO CLAIMANT SECTION ON THE OTHER SIDE OF THIS FORM OTHER NOTICES TO CLAIMANT: YOU ARE HEREBY NOTIFIED that the insurance carrier or self-i nsured employer admits that the fatality reported herein is compensable. YOU ARE ALSO NOTIFIED that if a child support obligation is owed, compensation benefits may be attached and payment of the child support obligation may be withheld and forwarded to the obligee pursuant to C.R.S. section 8-42-124 and C.R.S. section 26-13-122(4). YOU ARE FURTHER NOTIFIED that you must provide written notice of any award for social security, pension, disability or other source of income that might reduce your compensation benefits. This notice must be sent to the insurance carrier or self-insured employer within 20 days after learning of the payment or award. Failure to report may result in suspension of your benefits pursuant to C.R.S. section 8-42-113.5. Block # Adj. Code WC153 Rev 8/03 Page 2 of 2
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