Colorado > Workers Comp
Application For Indigent Determination (IME) WC35 IME - Colorado
| Application For Indigent Determination (IME) 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 APPLICATION FOR INDIGENT DETERMINATION (IME) Instructions to the Claimant: You have the right to submit an Application for Indigent Determination (IME) if you believe that you are unable to pay the fee(s) required to obtain a Division Independent Medical Examination. You must complete this Application and sign the affirmation on page four. The original Application shall be filed with the Office of Administrative Courts at 633 Seventeenth St., Suite 1300, Denver, CO 80202-3660 and a copy sent to all parties in the case. Claimant Employer Insurance carrier W.C. number Social security number Carrier number Household status of claimant: Single Separated Common Law Married Divorced Number of dependents: Spouse Children Other Ages of children: Bank accounts or other financial accounts: Checking Savings Other Amount of cash on hand At At At $ Account balance: $ $ $ $ Estimated Value of property and real estate owned: $ Amt. Owed: $ Vehicles owned: Year Year Make Make Value Value $ $ Amt. Owed: Amt. Owed: $ $ Gross monthly income of all household members: Monthly expenses of household: Earnings - claimant Earnings - spouse Earnings other members Stock, Bonds, Investments $ $ $ $ Rent/House payment Utilities Food Clothing $ $ $ $ WC035 IME 03/07 Page 1 of 4 American LegalNet, Inc. www.FormsWorkflow.com
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