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Workers' Compensation Forms

Forms by Number

NumberForm TitleRevised
WC1Employer's First Report of Injury(opens in new window)01/06
WC2General Admission of Liability(opens in new window)07/14
WC3Notice of One-Time Change of Physician & Authorization for Release of Medical Information(opens in new window)06/15
WC4Final Admission of Liability(opens in new window)03/19
WC6Entry of Appearance(opens in new window)01/24
WC12Supplemental Report of Return to Work(opens in new window)10/21
WC15Worker's Claim for Compensation(opens in new window)
(Este formulario debe completarse en Inglés.)
10/24
WC18Dependent's Notice and Claim for Compensation(opens in new window)10/24
WC30Designated Health Care Provider Disclosure Form(opens in new window)11/07
WC34Request to Erase (Redact) Medical Information from an Audio Recording(opens in new window)08/09
WC35Application for Indigent Determination (Hearing Transcript)(opens in new window)04/22
WC35 (DIME)Application for Indigent Determination (DIME)(opens in new window)10/19
WC36 - AIME Advisement for Claimant re: Audio-Recording of Exam (English Version)(opens in new window)12/18
WC36 - BIME Advisement for Claimant re: Audio-Recording of Exam (Spanish Version)(opens in new window)12/18
WC43

Rejection of Coverage for Corporate Officers or Limited Liability Company (LLC) Members and Construction Industry Partners or Sole Proprietors(opens in new window)

Digital Rejection of Coverage Form(opens in new window)

08/24
WC44Exclusion of Uncompensated Public Officials(opens in new window)03/23
WC45The WC45 was removed as of 8/26/2024. The WC43 must be used for all rejections of coverage.N/A
WC50

Notice to Employer of Injury Poster(opens in new window)

This poster is designed and must be posted as 27" wide by 40" high. Page 2 (the black and white English version) is the only version required to be posted. Spanish and color versions are included if carriers would also like to supply these other designs.


We have information for an available vendor, not necessarily a recommended vendor. The vendor is not a state agency and is not affiliated with the Division. So, if you have concerns or questions about your order, you need to work directly with the vendor. Visit the WC50 instructions document(opens in new window) for information on how to order through this outside vendor.

As of 8/10/2022, the WC49 posters are no longer required to be posted. 

08/22
WC54Petition to Modify, Terminate, or Suspend Compensation and Objection to Petition to Modify, Terminate, or Suspend Compensation(opens in new window)07/21
WC62Request For Lump Sum Payment(opens in new window)07/14
WC63Removed as of 11/8/202211/22
WC70Removed as of 11/8/202211/22
WC73Settlement Order(opens in new window)02/19
WC74Notice of Contest(opens in new window)
Please Note: This form is required to be filed electronically pursuant to Rule 5-1(C). See Rule 5-1(D) for exemptions from electronic filing
01/25
WC76Request for Appointment to the Independent Medical Examination Panel(opens in new window)07/24
WC77Notice and Proposal and Application for a Division Independent Medical Examination (DIME)(opens in new window)10/18
WC95Request for Insurer Information(opens in new window)10/18
WC98Monthly Summary(opens in new window)01/06
WC104Claim Settlement Agreement(opens in new window)08/19
WC105Settlement Routing Sheet(opens in new window)03/14
WC106First Report Transmittal(opens in new window)05/05
WC107Provider Compliance Agreement(opens in new window)02/18
WC109Request for Premium Cost Containment Certification(opens in new window)09/24
WC112Payroll Statement Form(opens in new window)12/24
WC113Surcharge Form(opens in new window)12/24
WC115Self-Insured Annual Review Form(opens in new window)07/19
WC120Self-Insurance Parental Guaranty Form(opens in new window)03/16
WC131Request for Utilization Review(opens in new window)05/16
WC132DIME Examiner's Summary Sheet(opens in new window)01/20

WC134

 

Request for Services(Email Use Only)(opens in new window)

Instructions for Request for Services(opens in new window)

01/24

10/20

WC151Fatal Case - General Admission(opens in new window)10/24
WC153Fatal Case - Final Admission(opens in new window)10/17
WC164Physician's Report of Workers' Compensation Injury(opens in new window)01/19
WC165Notice of DIME Negotiations(opens in new window)10/18
WC167Self-Insured PTD and Fatality Report(opens in new window)12/18
WC168Notice of Change of Carrier or Adjusting Firm(opens in new window)10/23
WC169Sender's Transmission Profile(opens in new window)07/02
WC170Sender's Trading Partner Profile(opens in new window)07/02
WC171Third-Party Administrator Location List(opens in new window)07/02
WC172Trading Partner Insurer List(opens in new window)07/02
WC174Worker's Claim for Compensation Transmittal(opens in new window)05/05
WC175EDI Sender Acceptance Form(opens in new window)07/02
WC178Request/Notification for Follow-up IME(opens in new window)04/23
WC179

Division IME Physician Summary Disclosure Form (Insurer or Self-Insured Employer)(opens in new window)

Complete the WC179 DIME Physician Summary Disclosure Online(opens in new window)

10/24
WC180Removed as of 11/29/2022 
WC181

Medical Billing Dispute Resolution Intake Form   (opens in new window)

Submit a Medical Billing Dispute Intake Online(opens in new window)

10/24
WC188Authorized Treating Provider's Request for Prior Authorization(opens in new window)12/21
WC189Authorization for Release of Information(opens in new window)03/23
WC190Authorization for Release of Limited Information to Third Parties(opens in new window)03/23
WC191Voluntary Abandonment of Claim(opens in new window)03/14
WC192Motion to Close for Failure to Prosecute and Order to Show Cause(opens in new window)04/19
WC193Request for Disfigurement Award (Photo)(opens in new window)01/24
WC194Certificate of Mailing(opens in new window)09/15
WC195Notification by an Authorized Treating Provider(opens in new window)02/19
WC196Rehabilitation Communication Form(opens in new window)09/16
WC197Request for Change of Physician(opens in new window)06/16
WC198Notice of Reschedule or Termination of the Division Independent Medical Examination (DIME)(opens in new window)04/20
WC200Notice of Agreement to Limit the Scope of the Division Independent Medical Examination (DIME)(opens in new window)10/18
WC201Division Independent Medical Examination (DIME) Report Template(opens in new window)10/18
WC202Application to the Colorado Uninsured Employer Fund(opens in new window)09/23
WC203Interpreter Invoice Form(opens in new window)01/25
WC204Colorado Uninsured Employer Fund Continuation Request(opens in new window)02/25
WCM3Permanent Work-Related Mental Impairment Rating Report Worksheet(opens in new window)04/18

If you would like a copy of any of the forms as a Word document, please email the Education & Outreach team at cdle_dowc_communications@state.co.us(opens in new window).


 

Forms by Type

FormNumberDescriptionRevised
General Admission of Liability(opens in new window)WC2This form is used by the insurer to voluntarily admit responsibility for payment of workers' compensation benefits. It is an important legal document that provides an initial statement of the amount of benefits to be paid in a workers' compensation case.07/14
Final Admission of Liability(opens in new window)WC4This form is the final statement by the insurer of the amount of benefits to be paid in a workers' compensation case. If there is no objection to the final admission by the claimant within the prescribed time frame, the admission becomes final and the claim is closed.03/19
Petition to Modify, Terminate, or(opens in new window)
Suspend Compensation(opens in new window)
WC54This form is used by an insurer to request that the Director modify, terminate, or suspend a claimant's temporary disability benefits based on facts that are outlined in the petition.07/21
Objection to Petition to Modify, Terminate, or Suspend CompensationWC55This form is used by the claimant to object to a Petition to Modify, Terminate or Suspend Compensation. This form is now combined with WC54 - Petition to Modify, Terminate, or Suspend Compensation. 
Notice of Contest(opens in new window)WC74This form is used by the insurer to deny liability responsibility for workers' compensation benefits.

Please Note: This form is required to be filed electronically pursuant to Rule 5-1(C). See Rule 5-1(D) for exemptions from electronic filing.
01/25
Fatal General Admission(opens in new window)WC151This form is used by the insurer to voluntarily admit responsibility for payment of workers' compensation benefits where a fatality has occurred. It is an important legal document that provides an initial statement of the amount of benefits to be paid in a workers' compensation case.10/24
Fatal Final Admission(opens in new window)WC153This form is the final statement by the insurer of the amount of benefits to be paid in a workers' compensation case where a fatality has occurred. If there is no objection to the final admission by the claimant within the prescribed time frame, the admission becomes final and the claim is closed.10/17

FormNumberDescriptionRevised
Notice of One-Time Change of Physician & Authorization for Release of Medical Information(opens in new window)WC3This form is used by an injured worker to request a one-time change of physician. The form also contains an authorization to release medical information to the new treating physician.06/15
Request for Change of Physician(opens in new window)WC197This form is required for use by the injured worker to request a change of physician. (If permission is neither granted or refused within 20 days, the insurer shall be deemed to have waived an objection.) The same form is required for use by the insurer when objecting to the request for change of physician.06/16

FormNumberDescriptionRevised
Request for Services(opens in new window) (Email Use Only)WC134This form is used to submit requests for services through the Division electronically.01/24
Instructions for WC134(opens in new window)WC134AInstructions for completing this form.10/20
Authorization for Release of Information(opens in new window)WC189This Division form serves as claimant authorization for release of workers' compensation documents.03/23
Authorization for Release of Limited Information to Third Parties(opens in new window)WC190This Division form serves as authorization for partial release of claimant information for pre-employment verification.03/23

FormNumberDescriptionRevised
Worker's Claim for Compensation(opens in new window)WC15This form is filed by the injured worker and provides notice to the Division and insurer that workers' compensation benefits are claimed.
(Este formulario debe completarse en Inglés.)
10/24
Dependent's Notice and Claim for Compensation(opens in new window)WC18This form is filed by the dependents of a deceased worker and provides notice to the Division and the insurer that workers' compensation dependent's benefits are claimed.10/24
Request for Disfigurement Award (Photo)(opens in new window)WC193This form is filed by the injured worker claiming benefits for permanent disfigurement. This form is filed with the Prehearing Conference Unit along with photographs that clearly show the disfigurement.01/24
Application to the Colorado Uninsured Employer Fund(opens in new window)WC202This form is filed by an injured worker who was injured on or after January 1, 2020, while working for an uninsured employer and has a final order from a judge finding that the injured worker is entitled to workers' compensation benefits.09/23
Colorado Uninsured Employer Fund Continuation Request(opens in new window)WC204Claimants receiving benefits from the Colorado Uninsured Employer Fund must complete and submit this form by April 1 to continue receiving benefits in the following fiscal year (July 1 - June 30).02/25

FormNumberDescriptionRevised
Voluntary Abandonment of Claim(opens in new window)WC191This form is used by the injured worker to voluntarily abandon all future benefits to which he or she may be entitled. The insurer must endorse the the form and certify that nothing of value has been offered in exchange for the waiver. The completed and endorsed form will be used by the insurer as the basis for filing a Final Admission of Liability.03/14

FormNumberDescriptionRevised
Application for Indigent Determination (DIME)(opens in new window)WC35This application is used by a claimant who is unable to pay the fee(s) required to obtain a Division Independent Medical Examination.10/19
Request for Appointment to the Independent Medical Examination Panel(opens in new window)WC76This form is used by a physician to apply for appointment as a Division Independent Medical Examiner.07/24
Notice and Proposal and Application for a Division Independent Medical Examination (DIME)(opens in new window)WC77This application, which includes the Notice and Proposal as of 1/1/2019, is used by a claimant or insurer to request and Independent Medical Examination (IME) through the Division for a determination of Maximum Medical Improvement (MMI), permanent impairment, or both.10/18
Independent Medical Examiner's Summary Sheet(opens in new window)WC132This form is used by the Division Independent Medical Examiner to summarize his/her findings.01/20
Notice of DIME Negotiations(opens in new window)WC165This form is used by the insurer to notify the Division that the parties have failed in the attempt to negotiate the selection of an Independent Medical Examination (IME) physician.10/18
Request/Notification for Follow-up IME(opens in new window)WC178This form must be submitted when the claimant previously had a Division IME and was determined to be "not at MMI", and the insurer/respondent is now requesting a follow-up IME. It may also be used on a reopened claim.04/23

Division IME Physician Summary Disclosure Form (Insurer or Self-Insured Employer)

Complete DIME Physician Summary Disclosure Online

WC179This form is provided upon request of a party to a Division IME. It is a summary disclosure of any business, financial, employment, or advisory relationship between the listed IME physician and [the insurer/self-insured employer].10/24
Division IME Physician Summary Disclosure Form (Claimant)WC180Removed as of 11/29/2022 
Notice of Reschedule or Termination of the(opens in new window)
Division Independent Medical Examination (DIME)(opens in new window)
WC198 04/20
Notice of Agreement to Limit the Scope of the Division Independent Medical Examination (DIME)(opens in new window)WC200 10/18
Division Independent Medical Examination (DIME) Report Template(opens in new window)WC201 10/18

FormNumberDescriptionRevised
Request to Erase (Redact) Medical Information from an Audio Recording(opens in new window)WC34This form must be used by an injured worker to request that a judge order information be erased from the audio recording taken during a medical evaluation. The request is based on the belief that the information is private and not related to the workers' compensation claim.08/09
IME Advisement - (English Version)(opens in new window)WC36-AThis form must be signed by an injured worker prior to undergoing an independent medical examination that will be audio recorded. It provides information on the injured workers' rights and responsibilities.12/18
IME Advisement - (Spanish Version)(opens in new window)WC36-BThis form must be signed by an injured worker prior to undergoing an independent medical examination that will be audio recorded. It provides information on the injured workers' rights and responsibilities.12/18

FormNumberDescription
EDI Sender's Transmission Profile(opens in new window)WC169This is an EDI form used by insurers to inform the Division of all allowable options in which data will be provided.
EDI Sender's Trading Partner Profile(opens in new window)WC170This is an EDI worksheet used by insurers to communicate to the Division, the Sender's contact information.
EDI Third Party Administrator Location List(opens in new window)WC171This is an EDI worksheet used by Third Party Administrators to provide the Division with Sender ID information in the header record of all EDI transactions.
EDI Trading Partner Insurer List(opens in new window)WC172This is an EDI worksheet used by Trading Partners to provide the Division with Sender ID information in the header record of all EDI transactions.
EDI Sender Acceptance(opens in new window)WC175This is an EDI form used by insurers in acceptance of the Colorado Electronic Data Interchange sender requirements.

Office of Administrative Courts (OAC) forms can be found here(opens in new window). The OAC forms are available in "printable" pdf format except for the Application for Indigent Determination which is a fillable format. File these forms with OAC at 1525 Sherman Street, 4th Floor, Denver, CO 80203. OAC forms are not filed with the Division of Workers' Compensation. If you have any questions concerning the OAC forms, please contact OAC at 303-866-2000.

FormNumberDescriptionRevised
Application for Indigent Determination (Hearing Transcript)(opens in new window)WC35This application is used by a claimant who is unable to pay the fee to obtain a transcript for the purpose of appealing a decision on a claim.04/22

FormNumberDescriptionRevised

Rejection of Coverage for Corporate Officers or Limited Liability Company (LLC) Members and Construction Industry Partners or Sole Proprietors(opens in new window)

Digital Rejection of Coverage Form(opens in new window)

WC43This form is used by corporate officers, members of a limited liability company, and construction industry partners or sole proprietors to reject workers' compensation insurance coverage.08/24
 
Exclusion of Uncompensated Officials(opens in new window)WC44This form is used by a public entity to exclude uncompensated elected or appointed officials from workers' compensation insurance coverage for the upcoming policy year.04/23
This form is no longer in use as of 8/26/2024WC45Removed as of 8/26/2024. The WC43 must be used for all rejections of coverage.N/A
Request for Premium Cost Containment CertificationWC109This form is used by employers to obtain certification status in the Colorado Workers' Compensation Premium Cost Containment Program.09/24

FormNumberDescriptionRevised

Medical Billing Dispute Resolution Intake(opens in new window)

Submit a Digital Medical Billing Resolution Intake Online(opens in new window)

WC181This form is used to initiate medical payment disputes between parties. The dispute will be reviewed by the Medical Policy Unit to determine compliance with Rules 16 and 18. If a disputed violation of Rules 16 and 18 has occurred, a Director's Order may be given which states the violation and outlines remedies and/or penalties to ensure future compliance.10/24

FormNumberDescriptionRevised
Request for Utilization Review(opens in new window)WC131This form is used by claimants and insurers to request a review of medical treatment that has been provided to a claimant.05/16

FormNumberDescriptionRevised
Petition to Reopen (No longer in use)WC37The WC37 was removed as of 7/1/2021. Claimants should utilize the Application for Hearing provided by the OAC(opens in new window).Removed
Petition to Modify, Terminate, or Suspend Compensation(opens in new window)WC54This form is used by an insurer to request that the director modify, terminate, or suspend a claimant's temporary disability benefits based on information outlined in the petition.07/21
Objection to Petition to Modify, Terminate, or Suspend Compensation(opens in new window)WC55This form is used by the claimant to object to the proposed modification, termination, or suspension of workers' compensation benefits by the Director. This form has been combined with WC54 - Petition to Modify, Terminate, or Suspend Compensation. 
Request For Lump Sum Payment(opens in new window)WC62Page 1 of this form is used by the claimant to request that permanent disability benefits be paid in a lump sum.
Page 2 of the form is used by the insurer to provide proof to the Division of accurate calculation and timely payment of benefits to all parties in a claim in which a permanent partial disability lump sum is requested.
Page 3 is used by the insurer to provide proof to the Division of accurate calculation and timely payment of benefits to all parties in a permanent total disability or fatal claim.
07/14

FormNumberDescriptionRevised
Motion to Close for Failure to Prosecute and Order to Show Cause(opens in new window)WC192Forms are filed together by the carrier, third party administrator, or respondent attorney in an effort to close a claim according to Rule 7-1(C). A properly captioned proposed Order to Show Cause is included in the packet, which is to be completed by the Division of Workers' Compensation.04/19

FormNumberDescriptionRevised
Notice of Change of Carrier or Adjusting Firm(opens in new window)WC168This form is used by the insurer or claims adjusting administrator to advise of any change in the claims administrator handling its workers' compensation claims.10/23

FormNumberDescriptionRevised
Designated Health Care Provider Disclosure(opens in new window)WC030This form is used by a designated health care provider when a request is made for information on ownership interests and employment relationships.11/07
Physician's Reports(opens in new window)WC164This form is used by the physician to provide information on the status, progress and medical treatment of the injured worker. It is also used to provide information on the date of maximum medical improvement and permanent impairment. A copy of the completed report is provided to both the insurer and the claimant.02/19
Permanent Mental Impairment Rating Worksheet(opens in new window)WC-M3 PsychThis worksheet is used by Level II Accredited Physicians to assign permanent mental impairment ratings.04/18
Pharmacy Billing StatementWC-M4 PsychRemoved 

FormNumberDescriptionRevised
Workers' Compensation Act Poster (Removed)WC49As of 8/10/2022, the WC49 posters are no longer required to be posted.Removed
Notice to Employer of Injury Poster(opens in new window)WC50

This poster must be displayed on the workplace premises and provides notice to the employee of the requirement to report all work-related injuries to the employer.

This poster is designed and must be posted as 27" wide by 40" high. 
Page 2 (the black and white English version) is the only version required to be posted. Spanish and color versions are included if carriers would also like to supply these other designs.
We have information for an available vendor, not necessarily a recommended vendor. The vendor is not a state agency and is not affiliated with the Division. So, if you have concerns or questions about your order, you need to work directly with the vendor. Visit the WC50 instructions document(opens in new window) for information on how to order through this outside vendor.

08/22

FormNumberDescriptionRevised
Entry of Appearance(opens in new window)WC6This form is used by attorneys. It serves as notification of legal representation on a specific workers' compensation case.01/24

FormNumberDescriptionRevised
Employer's First Report of Injury(opens in new window)WC1This report is filed in all instances where the employer has received notice or knowledge of a work related injury or occupational disease. The report may only be filed by the employer or employer representative. Please Note: This form is required to be filed electronically pursuant to Rule 5-1(C). See Rule 5-1(D) for exemptions from electronic filing.01/06
Supplemental Report of Return to Work(opens in new window)WC12This report is used by employers and claimants to provide the insurer with return to work information.10/21
Monthly Summary(opens in new window)WC98The Division requires that this report be filed by the insurer or self-insured employer, to report medical-only injuries or exposures to injurious substances (as defined by Director by rule), which did not result in a fatality, permanent impairment or time loss from work in excess of 3 days or 3 shifts.01/06

FormNumberDescriptionRevised
Request For Services (Email Use Only)(opens in new window)WC134This form is used to submit requests for services through the Division electronically.01/24
Instructions for WC134(opens in new window)WC134AInstructions for completing this form.04/16
Authorization for Release of Information(opens in new window)WC189This Division form serves as claimant authorization for release of workers' compensation documents.03/13

FormNumberDescriptionRevised
Settlement Order(opens in new window)WC73This is the standard Settlement Order submitted to the Director or Administrative Law Judge for settlement approval on represented claimants.02/19
Claim Settlement Agreement(opens in new window)WC104This is the standard settlement agreement for claimants required by the Division. See Rule 9, Division of Workers' Compensation Dispute Resolution.08/19
Settlement Routing Sheet(opens in new window)WC105This is a checklist used by attorneys. It accompanies settlement documents and is required by the Division to ensure all required information is included.03/14

FormNumberDescriptionRevised
Payroll Statement(opens in new window)WC112This form is used by self-insured employers to calculate the premium equivalent through the use of NCCI classification code number and payroll. For NCCI Hazard Group and Classification, documents click here.12/24
Surcharge Form(opens in new window)WC113This form is used by insurers to calculate applicable surcharge amounts.12/24

FormNumberDescriptionRevised
First Report Transmittal(opens in new window)WC106This form is used by the insurer to transmit Employer's First Reports of Injury to the Division.05/05
Worker's Claim for Compensation Transmittal(opens in new window)WC174This form is used by attorneys to submit Worker's Claims for Compensation and should be accompanied by an Entry of Appearance Form (WC6).01/17

Contact Us

Division of Workers' Compensation
633 17th Street, Suite 400
Denver, CO 80202
303-318-8700
1-888-390-7936 (Toll-Free)
cdle_wccustomer_service@state.co.us