Settlement Routing Sheet {WC105}

DIVISION OF WORKERS' COMPENSATION SETTLEMENT ROUTING SHEET Customer Service 303.318.8700 Claimant's name: List all workers' compensation (WC#) numbers included in this settlement: WC#: WC#: WC#: WC#: DOI DOI DOI DOI Claimant's Attorney Respondent's Attorney Other Attorney Other Attorney Reg. # Reg. # Reg. # Reg. # List all attorneys and corresponding registration numbers: Type of settlement (check one): Full and Final Settlement (F) Partial Settlement (P) Total amount of settlement award (Include lump sum plus present value of any structured settlement) $ Double check and verify the following ­ failure to do so could result in the rejection of your settlement agreement: 1. 2. 3. Workers' compensation numbers are correct . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Claimant's signature is properly notarized . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A standard order is included . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I have reviewed the attached settlement document and order, and believe they comply with the Division rules. Signature Date Print Name Instructions for order return: Pick up Mail (addressed, stamped envelopes for all parties are attached) Email: Contact person for document pickup: Phone number Name Phone number Contact person for information: Name This form must be completed and submitted with the settlement document and order. Include a mailing certificate if the order is to be mailed or electronically submitted. Submit the settlement document and copies for all parties listed on the mailing certificate. Failure to correctly complete and submit all documents may result in rejection or return of the settlement. Settlement documents for claimants not represented by an attorney must be submitted directly to the Prehearing Unit of the Division of Workers' Compensation. Do not complete this form if the claimant is unrepresented. Division of Workers' Compensation Use Only: Approved Date: By: By: Rejected (see # ____ above) Person picking up documents: Date: Print Name Signature On behalf of: Date: Mail or deliver all documents to: Division of Workers' Compensation, Customer Service 633 17th St., Suite 400, Denver, CO 80202-3626 cdle_dowc_settlements@state.co.us WC105 Rev 03/14 American LegalNet, Inc. www.FormsWorkFlow.com