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Workers' Compensation Forms

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Forms by Number

Form #Form TitleRevisedDownload Form
WC1Employer's First Report of Injury01/06PDFWord
WC2General Admission of Liability07/14PDFWord
WC3Notice of One-Time Change of Physician & Authorization for Release of Medical Information06/15PDFWord
WC4Final Admission of Liability03/19PDFWord
WC6Entry of Appearance01/24PDFWord
WC12Supplemental Report of Return to Work10/21PDFWord
WC15Worker's Claim for Compensation
(Este formulario debe completarse en Inglés.)
08/22PDFWord
WC18Dependent's Notice and Claim for Compensation08/22PDFWord
WC30Designated Health Care Provider Disclosure Form11/07PDFWord
WC34Request to Erase (Redact) Medical Information from an Audio Recording08/09PDFWord
WC35Application for Indigent Determination (Hearing Transcript)04/22PDFWord
WC35 (DIME)Application for Indigent Determination (DIME)10/19PDFWord
WC36 - AIME Advisement for Claimant re: Audio-Recording of Exam (English Version)12/18PDFWord
WC36 - BIME Advisement for Claimant re: Audio-Recording of Exam (Spanish Version)12/18PDFWord
WC43Rejection of Coverage by Corporate Officers or Members of a Limited Liability Company10/20PDFWord
WC44Exclusion of Uncompensated Public Officials03/23Google Form
WC45Rejection of Coverage By Partners and Sole Proprietors Performing Construction Work on Construction Sites10/20PDFWord
WC49As of 8/10/2022, the WC49 posters are no longer required to be posted.    
WC50Notice to Employer of Injury Poster08/22PDFNA
 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 this instructions document for information on how to order through this outside vendor.
WC54Petition to Modify, Terminate, or Suspend Compensation/
Objection to Petition to Modify, Terminate, or Suspend Compensation
07/21PDFWord
WC62Request For Lump Sum Payment07/14PDFWord
WC63Removed as of 11/8/202211/22  
WC70Removed as of 11/8/202211/22  
WC73Settlement Order02/19PDFWord
WC74Notice of Contest
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
09/18PDFWord
WC76Request for Appointment to the Independent Medical Examination Panel10/18PDFWord
WC77Notice and Proposal and Application for a Division Independent Medical Examination (DIME)10/18PDFWord
WC95Request for Insurer Information10/18PDFWord
WC98Monthly Summary01/06PDFWord
WC104Claim Settlement Agreement08/19PDFWord
WC105Settlement Routing Sheet03/14PDFWord
WC106First Report Transmittal05/05PDFWord
WC107Provider Compliance Agreement02/18PDFWord
WC109Request for Certification05/05PDFWord
WC112Payroll Statement Form12/23PDFWord
WC113Surcharge Form12/23PDFWord
WC115Self-Insured Annual Review Form07/19PDFN/A
WC120Self-Insurance Parental Guaranty Form03/16PDFN/A
WC131Request for Utilization Review05/16PDFWord
WC132DIME Examiner's Summary Sheet01/20PDFWord

WC134

 

Request for Services(Email Use Only)

Instructions

01/24

10/20

PDF

PDF

N/A

N/A

WC151Fatal Case - General Admission05/05PDFWord
WC153Fatal Case - Final Admission10/17PDFWord
WC164Physician's Report of Workers' Compensation Injury01/19PDFWord
WC165Notice of DIME Negotiations10/18PDFWord
WC167Self-Insured PTD and Fatality Report12/18PDFN/A
WC168Notice of Change of Carrier or Adjusting Firm10/23PDFWord
WC169Sender's Transmission Profile07/02PDFWord
WC170Sender's Trading Partner Profile07/02PDFWord
WC171Third-Party Administrator Location List07/02PDFWord
WC172Trading Partner Insurer List07/02PDFWord
WC174Worker's Claim for Compensation Transmittal05/05PDFWord
WC175EDI Sender Acceptance Form07/02PDFWord
WC178Request/Notification for Follow-up IME04/23PDFWord
WC179Division IME Physician Summary Disclosure Form (Insurer or Self-Insured Employer)10/18PDFWord
WC180Removed as of 11/29/2022   
WC181Medical Billing Dispute Resolution Intake Form   08/22PDFWord
  Google Form
WC188Authorized Treating Provider's Request for Prior Authorization12/21PDFWord
WC189Authorization for Release of Information03/23PDFWord
WC190Authorization for Release of Limited Information to Third Parties03/23PDFWord
WC191Voluntary Abandonment of Claim03/14PDFWord
WC192Motion to Close for Failure to Prosecute and Order to Show Cause04/19PDFWord
WC193Request for Disfigurement Award (Photo)01/24PDFWord
WC194Certificate of Mailing09/15PDFN/A
WC195Notification by an Authorized Treating Provider02/19PDFWord
WC196Rehabilitation Communication Form09/16PDFWord
WC197Request for Change of Physician06/16PDFWord
WC198Notice of Reschedule or Termination of the Division Independent Medical Examination (DIME)04/20PDFWord
WC199    
WC200Notice of Agreement to Limit the Scope of the Division Independent Medical Examination (DIME)10/18PDFWord
WC201Division Independent Medical Examination (DIME) Report Template10/18PDFWord
WC202Application to the Colorado Uninsured Employer Fund09/23PDFWord
WC203Interpreter Invoice Form01/23PDFWord
WC204Colorado Uninsured Employer Fund Continuation Request08/23PDFWord
WCM3Permanent Work-Related Mental Impairment Rating Report Worksheet04/18PDFWord
WCM4Pharmacy Billing Statement - (Removed)   
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Forms by Type

Form

#

Description

Revised

Downloads

General Admission of Liability

WC2

This 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

PDF

Word

Final Admission of Liability

WC4

This 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

PDF

Word

Petition to Modify, Terminate, or
Suspend Compensation

WC54

This 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

PDF

Word

Objection to Petition to Modify, Terminate, or Suspend Compensation

WC55

This 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

WC74

This 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.

04/08

PDF

Word

Fatal General Admission

WC151

This 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.

05/05

PDF

Word

Fatal Final Admission

WC153

This 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

PDF

Word

Form

# Description Revised Downloads
Notice of One-Time Change of Physician & Authorization for Release of Medical Information WC3 This 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 PDF Word
Request for Change of Physician WC197 This 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 PDF Word

Form#DescriptionRevisedDownloads
Request for Services (Email Use Only)WC134This form is used to submit requests for services through the Division electronically.01/24PDF
Instructions for WC134WC134AInstructions for completing this form.10/20PDF
Authorization for Release of InformationWC189This Division form serves as claimant authorization for release of workers' compensation documents.03/23PDFWord
Authorization for Release of Limited Information to Third PartiesWC190This Division form serves as authorization for partial release of claimant information for pre-employment verification.03/23PDFWord

Form#DescriptionRevisedDownloads
Worker's Claim for CompensationWC15This 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.)
08/22PDFWord
Dependent's Notice and Claim for CompensationWC18This 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.08/22PDFWord
Request for Disfigurement Award (Photo)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.01/24PDFWord
Application to the Colorado Uninsured Employer FundWC202This 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.09/23PDFWord
Colorado Uninsured Employer Fund Continuation RequestWC204Claimants 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).08/23PDFWord

Form

#

Description

Revised

Downloads

Voluntary Abandonment of Claim

WC191

This 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

PDF

Word

Form

#

Description

Revised

Downloads

Application for Indigent Determination (DIME)

WC35

This application is used by a claimant who is unable to pay the fee(s) required to obtain a Division Independent Medical Examination.

10/19

PDF

Word

Request for Appointment to the Independent Medical Examination Panel

WC76

This form is used by a physician to apply for appointment as a Division Independent Medical Examiner.

10/18

PDF

Word

Notice and Proposal and Application for a Division Independent Medical Examination (DIME)

WC77

This 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

PDF

Word

Independent Medical Examiner's Summary Sheet

WC132

This form is used by the Division Independent Medical Examiner to summarize his/her findings.

01/20

PDF

Word

Notice of DIME Negotiations

WC165

This 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

PDF

Word

Request/Notification for Follow-up IME

WC178

This 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

PDF

Word

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

WC179

This 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].

10/18

PDF

Word

Division IME Physician Summary Disclosure Form (Claimant)

WC180

Removed as of 11/29/2022

 

 

 

Notice of Reschedule or Termination of the
Division Independent Medical Examination (DIME)
WC198   04/20 PDF Word
Notice of Agreement to Limit the Scope of the Division Independent Medical Examination (DIME) WC200   10/18 PDF Word
Division Independent Medical Examination (DIME) Report Template WC201   10/18 PDF Word

Form

#

Description

Revised

Downloads

Request to Erase (Redact) Medical Information from an Audio Recording

WC34

This 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.

 

PDF

Word

IME Advisement - (English Version)

WC36-A

This 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

PDF

Word

IME Advisement - (Spanish Version)

WC36-B

This 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

PDF

Word

Form

#

Description

Revised

Downloads

EDI Sender's Transmission Profile

WC169

This is an EDI form used by insurers to inform the Division of all allowable options in which data will be provided.

 

PDF

Word

EDI Sender's Trading Partner Profile

WC170

This is an EDI worksheet used by insurers to communicate to the Division, the Sender's contact information.

 

PDF

Word

EDI Third Party Administrator Location List

WC171

This 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.

 

PDF

Word

EDI Trading Partner Insurer List

WC172

This is an EDI worksheet used by Trading Partners to provide the Division with Sender ID information in the header record of all EDI transactions.

 

PDF

Word

EDI Sender Acceptance

WC175

This is an EDI form used by insurers in acceptance of the Colorado Electronic Data Interchange sender requirements.

 

PDF

Word

Form

#

Description

Revised

Downloads

Links to Office of Administrative Courts (OAC) forms are listed below. 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. To access the OAC forms, please click here.

Application for Indigent Determination (Hearing Transcript)

WC35

This 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

PDF

Word

Form

#

Description

Revised

Downloads

Rejection of Coverage By Corporate Officers Or Member Of A Limited Liability Company

WC43

This form is used by corporate officers or members of a limited liability company to reject workers' compensation insurance coverage.

10/20

PDF

Word

Exclusion of Uncompensated Officials

WC44

This 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

Google Form

Rejection of Coverage By Partners and Sole Proprietors Performing Construction Work on Construction Sites

WC45

This form is used by partners and sole proprietors performing construction work on construction sites to reject workers' compensation insurance coverage.

10/20

PDF

Word

Request for Certification

WC109

This form is used by employers to obtain certification status in the Colorado Workers' Compensation Premium Cost Containment Program.

 

PDF

Word

Form

#

Description

Revised

Downloads

Medical Billing Dispute Resolution Intake

WC181

This 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.

08/22

PDF

Word

      Google Form

Form

#

Description

Revised

Downloads

Request for Utilization Review

WC131

This form is used by claimants and insurers to request a review of medical treatment that has been provided to a claimant.

05/16

PDF

Word

Form

#

Description

Revised

Downloads

Petition to Reopen

WC37

This form is used by the claimant to request that a workers' compensation claim be reopened. (Removed as of 7/1/2021. Claimants should utilize the Application for Hearing provided by the OAC.)

01/06

PDF

Word

Petition to Modify, Terminate, or Suspend Compensation

WC54

This 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

PDF

Word

Objection to Petition to Modify, Terminate, or Suspend Compensation

WC55

This 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.

  N/A N/A

Request For Lump Sum Payment

WC62

Page 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

PDF

Word

Form # Description Revised Downloads
Motion to Close for Failure to Prosecute and Order to Show Cause WC192 Forms 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 PDF Word

Form

#

Description

Revised

Downloads

Notice of Change of Carrier or Adjusting Firm

WC168

This 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

PDF

Word

Form

#

Description

Revised

Downloads

Designated Health Care Provider Disclosure

WC030

This form is used by a designated health care provider when a request is made for information on ownership interests and employment relationships.

 

PDF

Word

Physician's Reports

WC164

This 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

PDF

Word

Permanent Mental Impairment Rating Worksheet

WC-M3 Psych

This worksheet is used by Level II Accredited Physicians to assign permanent mental impairment ratings.

04/18

PDF

Word

Pharmacy Billing Statement

WC-M4 Psych

Removed

 

 

 

Form

#

Description

Revised

Downloads

Workers' Compensation Act Poster

WC49-A

This poster must be displayed on the workplace premises and provides information on possible workers' compensation entitlements and insurance coverage. The poster is a sample of the text only in English.

 

 

Workers' Compensation Act Poster

WC49-B

The poster is a sample of the text only in Spanish.

 

 

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

Notice to Employer of Injury Poster

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 this instructions document for information on how to order through this outside vendor.

08/22

PDF

Form#DescriptionRevisedDownloads
Entry of AppearanceWC6This form is used by attorneys. It serves as notification of legal representation on a specific workers' compensation case.01/24PDFWord

Form

#

Description

Revised

Downloads

Employer's First Report of Injury

WC1

This 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

PDF

Word

Supplemental Report of Return to Work

WC12

This report is used by employers and claimants to provide the insurer with return to work information.

10/21

PDF

Word

Monthly Summary

WC98

The 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

PDF

Word

Form#DescriptionRevisedDownloads
Request For Services(Email Use Only)WC134This form is used to submit requests for services through the Division electronically.01/24PDF
Instructions for WC134WC134AInstructions for completing this form.04/16PDF
Authorization for Release of InformationWC189This Division form serves as claimant authorization for release of workers' compensation documents.03/13PDFWord

Form

#

Description

Revised

Downloads

Settlement Order

WC73

This is the standard Settlement Order submitted to the Director or Administrative Law Judge for settlement approval on represented claimants.

02/19

PDF

Word

Claim Settlement Agreement

WC104

This is the standard settlement agreement for claimants required by the Division. See Rule 9, Division of Workers' Compensation Dispute Resolution.

08/19

PDF

Word

Settlement Routing Sheet

WC105

This 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

PDF

Word

Form#DescriptionRevisedDownloads
Payroll StatementWC112This 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.12/23PDFWord
SurchargeWC113This form is used by insurers to calculate applicable surcharge amounts.12/23PDFWord

Form

#

Description

Revised

Downloads

First Report Transmittal

WC106

This form is used by the insurer to transmit Employer's First Reports of Injury to the Division.

 

PDF

Word

Worker's Claim for Compensation Transmittal

WC174

This form is used by attorneys to submit Worker's Claims for Compensation and should be accompanied by an Entry of Appearance Form (WC6).

 

PDF

Word

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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