Forms

Forms by Number

Form # Form Title Revised Download Form
WC1 Employer's First Report of Injury 01/06 PDF Word
WC2 General Admission of Liability 07/14 PDF Word
WC3 Notice of One-Time Change of Physician & Authorization for Release of Medical Information 06/15 PDF Word
WC4 Final Admission of Liability 03/19 PDF Word
WC6 Entry of Appearance 08/15 PDF Word
WC12 Supplemental Report of Return to Work 08/19 PDF Word
WC15 Worker's Claim for Compensation 03/11 PDF Word
WC18 Dependent's Notice and Claim for Compensation 04/06 PDF Word
WC30 Designated Health Care Provider Disclosure Form 11/07 PDF Word
WC34 Request to Erase (Redact) Medical Information from an Audio Recording 08/09 PDF Word
WC35 Application for Indigent Determination (Hearing Transcript) 01/06 PDF Word
WC35 (DIME) Application for Indigent Determination (DIME) 10/19 PDF Word
WC36 - A IME Advisement for Claimant re: Audio-Recording of Exam (English Version) 12/18 PDF Word
WC36 - B IME Advisement for Claimant re: Audio-Recording of Exam (Spanish Version) 12/18 PDF Word
WC37 Petition to Reopen 01/06 PDF Word
WC43 Rejection of Coverage by Corporate Officers or Members of a Limited Liability Company 10/20 PDF Word
WC44 Exclusion of Uncompensated Public Officials 02/12 PDF Word
WC45 Rejection of Coverage By Partners and Sole Proprietors Performing Construction Work on Construction Sites 10/20 PDF Word
WC49 - A Workers Compensation Act Poster (English Version) 05/19 PDF Word
WC49 - B Workers Compensation Act Poster (Spanish Version) 06/19 PDF Word
WC50 Notice to Employer of Injury Poster 05/99 PDF Word
WC54 Petition to Modify, Terminate, or Suspend Compensation/
Objection to Petition to Modify, Terminate, or Suspend Compensation
04/20 PDF Word
WC55 Objection to Petition to Modify, Terminate, or Suspend Compensation
(now combined with WC54 - Petition to Modify, Terminate, or Suspend Compensation)
     
WC62 Request For Lump Sum Payment 07/14 PDF Word
WC63 Request for Offset of Liability to Subsequent Injury Fund 01/06 PDF Word
WC70 Application for Admission to the Colorado Major Medical Insurance Fund 01/06 PDF Word
WC73 Settlement Order 02/19 PDF Word
WC74 Notice 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
04/08 PDF Word
WC76 Request for Appointment to the Independent Medical Examination Panel 10/18 PDF Word
WC77 Notice and Proposal and Application for a Division Independent Medical Examination (DIME) 10/18 PDF Word
WC95 Request for Insurer Information 10/18 PDF Word
WC98 Monthly Summary 01/06 PDF Word
WC104 Claim Settlement Agreement 08/19 PDF Word
WC105 Settlement Routing Sheet 03/14 PDF Word
WC106 First Report Transmittal 05/05 PDF Word
WC107 Provider Compliance Agreement 02/18 PDF Word
WC109 Request for Certification 05/05 PDF Word
WC112 Payroll Statement Form 06/20 PDF Word
WC113 Surcharge Form 06/20 PDF Word
WC131 Request for Utilization Review 05/16 PDF Word
WC132 IME Examiner's Summary Sheet 01/20 PDF Word

WC134

WC 134A

Request for Services(Email Use Only)

Instructions

04/20

10/20

PDF

PDF

N/A

N/A

WC151 Fatal Case - General Admission 05/05 PDF Word
WC153 Fatal Case - Final Admission 10/17 PDF Word
WC164 Physician's Report of Workers' Compensation Injury 01/19 PDF Word
WC165 Notice of DIME Negotiations 10/18 PDF Word
WC168 Notice of Change of Carrier or Adjusting Firm 05/19 PDF Word
WC169 Sender's Transmission Profile 07/02 PDF Word
WC170 Sender's Trading Partner Profile 07/02 PDF Word
WC171 Third Party Administrator Location List 07/02 PDF Word
WC172 Trading Partner Insurer List 07/02 PDF Word
WC174 Worker's Claim for Compensation Transmittal 05/05 PDF Word
WC175 EDI Sender Acceptance Form 07/02 PDF Word
WC178 Request/Notification for Follow-up IME 10/18 PDF Word
WC179 Division IME Physician Summary Disclosure Form (Insurer or Self-Insured Employer) 10/18 PDF Word
WC180 Division IME Physician Summary Disclosure Form (Claimant) 06/10 PDF Word
WC181 Medical Billing Dispute Resolution Intake Form 03/18 PDF Word
WC188 Authorized Treating Provider's Request for Prior Authorization 02/19 PDF Word
WC189 Authorization for Release of Information 06/18 PDF Word
WC190 Authorization for Release of Limited Information to Third Parties 06/18 PDF Word
WC191 Voluntary Abandonment of Claim 03/14 PDF Word
WC192 Motion to Close for Failure to Prosecute and Order to Show Cause 04/19 PDF Word
WC193 Request for Disfigurement Award (Photo) 07/18 PDF Word
WC194 Certificate of Mailing 09/15 PDF N/A
WC195 Notification by an Authorized Treating Provider 02/19 PDF Word
WC196 Rehabilitation Communication Form 09/16 PDF Word
WC197 Request for Change of Physician 06/16 PDF Word
WC198 Notice of Reschedule or Termination of the Division Independent Medical Examination (DIME) 04/20 PDF Word
WC199        
WC200 Notice of Agreement to Limit the Scope of the Division Independent Medical Examination (DIME) 10/18 PDF Word
WC201 Division Independent Medical Examination (DIME) Report Template 10/18 PDF Word
WC202 Application to the Colorado Uninsured Employer Fund 01/20 PDF Word
WCM3 Permanent Work-Related Mental Impairment Rating Report Worksheet 04/18 PDF Word
WCM4 Pharmacy Billing Statement 01/06 PDF Word


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.

04/20

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

#

Description

Revised

Downloads

Request for Services (Email Use Only)

WC134

This form is used to submit requests for services through the Division electronically.

04/20

PDF

Instructions for WC134 WC134A Instructions for completing this form. 10/20 PDF

Authorization for Release of Information

WC189

This Division form serves as claimant authorization for release of workers' compensation documents.

06/18

PDF

Word

Authorization for Release of Limited Information to Third Parties

WC190

This Division form serves as authorization for partial release of claimant information for pre-employment verification.

06/18

PDF

Word

Form

#

Description

Revised

Downloads

Worker's Claim for Compensation

WC15

This form is filed by the injured worker and provides notice to the Division and insurer that workers' compensation benefits are claimed.

03/11

PDF

Word

Dependent's Notice and Claim for Compensation

WC18

This 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.

04/06

PDF

Word

Request for Disfigurement Award (Photo) WC193 This 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. 04/15 PDF Word
Application to the Colorado Uninsured Employer Fund WC202 This 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. 01/20 PDF Word

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.

10/18

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

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 claimant].

06/10

PDF

Word

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.

01/06

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.

02/12

PDF

Word

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

Request for Offset of Liability to Subsequent Injury Fund

WC63

This form is used by the insurer to request that the Subsequent Injury Fund assume responsibility for payment of compensation and/or medical benefits.

 

PDF

Word

Application for Admission to the Colorado Major Medical Insurance Fund

WC70

This application is used by the insurer to request that the Major Medical Insurance Fund assume responsibility for payment of medical benefits, following expenditures of $20,000.00 or more in medical benefits by the insurer. It is applicable to injuries occurring on or after 7/1/71 to 7/1/81.

 

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.

03/18

PDF

Word

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.

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.

04/20

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.

05/19

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

This form is used by the Pharmacy to bill the carrier for payment.

 

PDF

Word

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.

 

PDF

Word

Workers' Compensation Act Poster

WC49-B

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

 

PDF

Word

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. In addition, notice is provided that benefits may be reduced if the injury results from use of a controlled substance.

 

PDF

Word

Form

#

Description

Revised

Downloads

Entry of Appearance

WC6

This form is used by attorneys. It serves as notification of legal representation on a specific workers' compensation case.

08/15

PDF

Word

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.

08/19

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 # Description Revised Downloads

Request For Services(Email Use Only)

WC134

This form is used to submit requests for services through the Division electronically.

04/20

PDF

Instructions for WC134 WC134A Instructions for completing this form. 04/16 PDF
Authorization for Release of Information WC189 This Division form serves as claimant authorization for release of workers' compensation documents. 03/13 PDF Word

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

#

Description

Revised

Downloads

Payroll Statement

WC112

This 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.

06/20

PDF

Word

Surcharge

WC113

This form is used by insurers to calculate applicable surcharge amounts.

06/20

PDF

Word

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

Contact Us

Division of Workers' Compensation
633 17th Street, Suite 400
Denver, CO 80202
303-318-8700
1-888-390-7936 (Toll-Free)
303-318-8710 (Fax)
cdle_wccustomer_service@state.co.us