Notice Of Change Of Carrier or Adjusting Firm {WC168}

COLORADO DEPARTMENT OF LABOR AND EMPLOYMENTDIVISION OF WORKERS222 COMPENSATIONNotice of Change of Carrier or Adjusting FirmEvery insurance carrier, or its designated claims adjusting administrator, in or out of state, per Rule 5-13(A), shall provide, within 30 days, any change in the claims administrator, in writing to both the claimant and the Division. The list submitted to the Division shall include claimant name, social security number, date of injury, carrier claim number, and workers222 compensation claim number, if available.Notice to claimant shall include the name, address, and toll-free telephone number of the new claims administrator(s). Employer New Claims Administrator:Name þ Address þ Address þ City, State, Zip Contact Person and Telephone Number Block Number þ (and/or) Adjusting Code FEIN Name þ Address þ Address þ City, State, Zip Contact Person and Telephone Number Block Number þ (and/or) Adjusting Code FEIN CHECK ALL THAT APPLY þ This change involves claims handled by the previous claims administrator.This change involves claims from (date).This change involves claims with date of injury from forward.Other - The change involves claims (explain)List all claims that will be handled by a new administrator. To submit this information electronically, you Claimant NameCarrier Claim NumberThis form has been completed by Signature þ Date þ Phone Title þ Company WC168 Rev 05/19 þ Page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com