Colorado > Workers Comp
Final Admission Of Liability WC4 - Colorado
| Final Admission Of Liability Form. This is a Colorado form and can be used in Workers Comp . |
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FINAL ADMISSION OF LIABILITY Workers' Compensation (WC) # Claimant's Name Social Security # Date of Injury Carrier Claim # Insurance Carrier 999999999999999 Average Weekly Wage Date First Payment of TTD Date of MMI Date First Payment of PPD 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 calendardays of the date of the final admission, your file will automatically close. Objection information is attached. If you disagree with the benefits admitted or not admitted you must do the following: 1. Within 30 days, complete the attached objection form or write a letter to the Division of Workers' Compensation, 633 17th St., Suite 400 Denver, CO 80202-3660 with a copy to the insurance carrier or self-insured employer stating that you object to this admission. You must also file an application for hearing with the Office of Administrative Courts on any disputed issues. Within the same 30 days, if you disagree with the date of MMI or whole person impairment rating, complete the attached Notice and Proposal to Select an Independent Medical Examiner form and send it to the insurance carrier or self-insured employer and the Division. If an IME is requested, you are not required to file an application for hearing until after the IME is completed. If your date of injury is prior to July 1, 1991, the provisions regarding an Independent Medical Examination do not apply. 2. 3. 4. See page 2 for codes, definitions and other important notices. BENEFIT SUMMARY (Check box & list amount for admitted benefits) Medical to Date (total) $ Disfigurement (total) $ Vocational Rehabilitation Services (total) $ Temporary Total Disability (TTD) (total) $ Temporary Partial Disability (TPD) (total) $ Stipulation $ Permanent Total Disability (PTD) Safety Rule Violation Offset (Attach Calculation) Permanent Partial Disability (PPD): Whole Person Impairment or Scheduled Impairment % Part of Body Code Scheduled Impairment % Part of Body Code (See page 2 for Part of Body Codes) % Age Position on Medical Benefits after Maximum Medical Improvement (MMI): Remarks and basis for permanent disability award: (Attach additional pages, if needed) BENEFIT HISTORY Type of Benefits Time Periods Weeks Rate per Week Totals through through through through through through through The above time periods include the dates specified. (Attach additional pages, if needed) Claims Representative Address Phone # = = = = = = = x x x x x x x $ $ $ $ $ $ $ = = = = = = = $ $ $ $ $ $ $ Amount of Interest Paid $ Amount of Penalties Paid $ Amount Overpaid $ (See Remarks) Toll-Free Phone # CERTIFICATE OF MAILING: Copies of this document were placed in the U.S. mail or delivered to the following parties this _____ day of _______________, _________. List names and addresses of all persons copied: Name Address Claimant: Claimant's Attorney: Employer: Carrier's Attorney: Division of Workers' Compensation, 633 17th Street, Suite 400, Denver, CO 80202-3660 By WC4 Rev 0 /1 Page 1 of 4 see page 2 for important notices and codes Block # Adj. Code American LegalNet, Inc. www.FormsWorkFlow.com NOTICE TO CLAIMANT: YOU ARE HEREBY 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. BENEFITS: Compensation benefits are paid by insurance carriers for compensable injuries. Temporary disability benefits are paid every two weeks. Medical Benefits - Current medical benefits for medical, hospital and surgical supplies, prescriptions, crutches, apparatus and vocational rehabilitation. Maximum Medical Improvement (MMI) - The date when any medically determinable physical or mental condition as a result of injury has become stable and when no further treatment is reasonably expected to improve the condition. Facial or Bodily Disfigurement - Payable for serious, permanent disfigurement about the head, face, or parts of the body normally exposed to public view. The maximum benefit is established each year for injuries that occur during that year. In addition, for injuries that occurred on or after July 1, 2007, it is possible to receive a larger amount for extensive disfigurement. Information regarding the maximum benefit for your date of injury is located on the Division's website, or you may contact the Customer Service Unit at (303) 318-8700. Temporary Total Disability (TTD) - Total disability of more than 3 working days. If disability lasts for more than 14 calendar days, compensation shall be paid from the day the claimant left work. Compensation is payable at the rate of 66 2/3% of the average weekly wage in effect at the time of the injury not to exceed the statutory maximum. A loss of fringe benefits specifically enumerated in the statute should be included in the calculation of the average weekly wage. Temporary Partial Disability (TPD) - Temporary partial disability of more than three working days. Compensation is payable at the rate of 66 2/3% of the difference between the employee's average weekly wage at the time of injury and the employee's average weekly wage during the continuance of the temporary partial disability not to exceed the statutory maximum. Permanent Partial Disability (PPD) - For dates of injury on or after July 1, 1991, an award for PPD is based on permanent impairment as defined by the authorized treating physician and is limited to the part of the body that is affected. Whole Person Impairment - Loss of function affecting body parts, including mental, not listed under the schedule below. Scheduled Impairment - Loss of function affecting the toes, feet, legs, fingers, hands, arms, eyes, vision and deafness. Codes for scheduled impairment ratings used by insurance carriers are listed below: Part of body codes
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