Colorado > Workers Comp
General Admission Of Liability WC2 - Colorado
| General Admission Of Liability Form. This is a Colorado form and can be used in Workers Comp . |
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COLORADO DEPARTMENT OF LABOR & EMPLOYMENT DIVISION OF WORKERS' COMPENSATION GENERAL ADMISSION OF LIABILITY WC # Carrier # TO: Claimant's Name Claimant's Address Soc. Sec. # Employer Date of Injury Average Weekly Wage Date first payment paid TTD and DIVISION OF WORKERS' COMPENSATION Date first payment PPD Date of MMI YOU ARE HEREBY NOTIFIED that the insurance carrier or self-insured employer (named below) admits that the injury or occupational disease 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 sections 8-42-124 and 26-13-122(4), C.R.S. 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 section 8-42-113.5, C.R.S. Liability is admitted for the following benefits: Safety Rule Violation medical benefits temporary total disability temporary partial disability rehabilitation maintenance benefits disfigurement permanent partial disability Complete the following if admitting for disability Type of Benefit Time Periods thru thru thru thru thru thru thru The above time periods represent inclusive dates. Remarks: Carrier or Self-Insured NOTICE TO CLAIMANT: IF YOU DISAGREE WITH THE AMOUNT OR TYPE OF BENEFITS WHICH THE CARRIER HAS AGREED TO PAY, YOU MAY WRITE A LETTER TO THE DIVISION OF WORKERS' COMPENSATION, 633 17TH ST., SUITE 400, DENVER, CO 80202-3660, STATING THAT YOU OBJECT TO THIS ADMISSION OF LIABILITY. Address See Reverse Side for Codes Offset Amount of Interest Paid $ Amount of Penalties Paid $ Working unit 1. Schedule Injury 2. Schedule Injury Attach Calculation % Disability % % Rate per Week Age (part of body) (part of body) Totals $ $ $ $ $ $ $ = = = = = = = wks wks wks wks wks wks wks $ $ $ $ $ $ $ Telephone No. By: Adjuster or Claims Representative Copies of this admission were mailed this Claimant's Attorney WC2 Rev 0 /1 Employer day of , to: Respondent's Attorney Block # Claimant Adj. Code American LegalNet, Inc. www.FormsWorkFlow.com Division of Workers' Compensation PLEASE READ REVERSE SIDE BENEFITS Compensation benefits are paid by insurance carriers for compensable injuries. Temporary disability benefits are paid every 2 weeks. Temporary Total Disability - Total disability of more than 3 working days. If disability lasts for more than 14 calendar days, compensation shall be paid from the day left work. Compensation is payable at the rate of 66 2/3% average weekly wage in effect at the time the injury/exposure 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. Permanent Partial Disability - Payable where there is residual impairment, based upon the part of the body affected, or on the extent of medical impairment. 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. Medical Benefits - Current medical benefits for medical, hospital and surgical supplies, prescriptions, crutches, apparatus and vocational rehabilitation. Temporary Partial Disability - Temporary partial disability of more than 3 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 said employee's average weekly wage during the continuance of the temporary partial disability not to exceed a maximum of 91% of the state average weekly wage per week. MMI - Maximum Medical Improvement means a point in time where any medically determinable physical or mental impairment as a result of injury has become stable and when no further treatment is reasonably expected to improve the condition. Codes for scheduled ratings: 01 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 Arm @ Shoulder Hand @ Wrist Thumb @Metacarpal Thumb @ Proximal Thumb @ Distal Index @ Metacarpal Index @ Proximal Index @ Second Index @ Distal Middle @ Metacarpal Middle @ Proximal Middle @ Second Middle @ Distal Ring @ Metacarpal Ring @ Proximal Ring @ Second Ring @ Distal Little @ Metacarpal 20 Little @ Proximal 21 Little @ Second 22 Little @ Distal 23 Leg @ Hip 25 Leg @ Foot, Heel, Ankle 26 Great Toe @ Metatarsal 27 Great Toe @ Proximal 28 Great Toe @ Distal 29 Other Toe @ Metatarsal 30 Other Toe @ Proximal 31 Other Toe @ Distal 32 Eye Enucleation 33 Blindness One Eye 34 Deafness Both Ears 35 Deafness One Ear 36 Total Hearing 2nd Ear 37 Loss of a Tooth WC2 Rev. 04/11 American LegalNet, Inc. www.FormsWorkFlow.com
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