Forms by Number
| Form # | Form Title | Revised | Download Form | |
| WC1 | Employer's First Report of Injury | 01/06 | Word | |
| WC2 | General Admission of Liability | 07/14 | Word | |
| WC3 | Notice of One-Time Change of Physician & Authorization for Release of Medical Information | 06/15 | Word | |
| WC4 | Final Admission of Liability | 03/19 | Word | |
| WC6 | Entry of Appearance | 08/15 | Word | |
| WC12 | Supplemental Report of Return to Work | 10/21 | Word | |
| WC15 | Worker's Claim for Compensation (Este formulario debe completarse en Inglés.) |
08/22 | Word | |
| WC18 | Dependent's Notice and Claim for Compensation | 08/22 | Word | |
| WC30 | Designated Health Care Provider Disclosure Form | 11/07 | Word | |
| WC34 | Request to Erase (Redact) Medical Information from an Audio Recording | 08/09 | Word | |
| WC35 | Application for Indigent Determination (Hearing Transcript) | 04/22 | Word | |
| WC35 (DIME) | Application for Indigent Determination (DIME) | 10/19 | Word | |
| WC36 - A | IME Advisement for Claimant re: Audio-Recording of Exam (English Version) | 12/18 | Word | |
| WC36 - B | IME Advisement for Claimant re: Audio-Recording of Exam (Spanish Version) | 12/18 | Word | |
| WC43 | Rejection of Coverage by Corporate Officers or Members of a Limited Liability Company | 10/20 | Word | |
| WC44 | Exclusion of Uncompensated Public Officials | 03/23 | Google Form | |
| WC45 | Rejection of Coverage By Partners and Sole Proprietors Performing Construction Work on Construction Sites | 10/20 | Word | |
| WC49 | As of 8/10/2022, the WC49 posters are no longer required to be posted. | |||
| WC50 | Notice to Employer of Injury Poster | 08/22 | NA | |
|
This poster is designed and must be posted as 27" wide by 40" high. |
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| WC54 | Petition to Modify, Terminate, or Suspend Compensation/ Objection to Petition to Modify, Terminate, or Suspend Compensation |
07/21 | Word | |
| WC62 | Request For Lump Sum Payment | 07/14 | Word | |
| WC63 | Removed as of 11/8/2022 | 11/22 | ||
| WC70 |
Removed as of 11/8/2022 |
11/22 | ||
| WC73 | Settlement Order | 02/19 | 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 |
09/18 | Word | |
| WC76 | Request for Appointment to the Independent Medical Examination Panel | 10/18 | Word | |
| WC77 | Notice and Proposal and Application for a Division Independent Medical Examination (DIME) | 10/18 | Word | |
| WC95 | Request for Insurer Information | 10/18 | Word | |
| WC98 | Monthly Summary | 01/06 | Word | |
| WC104 | Claim Settlement Agreement | 08/19 | Word | |
| WC105 | Settlement Routing Sheet | 03/14 | Word | |
| WC106 | First Report Transmittal | 05/05 | Word | |
| WC107 | Provider Compliance Agreement | 02/18 | Word | |
| WC109 | Request for Certification | 05/05 | Word | |
| WC112 | Payroll Statement Form | 06/23 | Word | |
| WC113 | Surcharge Form | 06/23 | Word | |
| WC115 | Self-Insured Annual Review Form | 07/19 | N/A | |
| WC120 | Self-Insurance Parental Guaranty Form | 03/16 | N/A | |
| WC131 | Request for Utilization Review | 05/16 | Word | |
| WC132 | DIME Examiner's Summary Sheet | 01/20 | Word | |
|
WC134 WC 134A |
Request for Services(Email Use Only) Instructions For WC Act Requests |
04/20 10/20 04/20 |
N/A N/A |
|
| WC151 | Fatal Case - General Admission | 05/05 | Word | |
| WC153 | Fatal Case - Final Admission | 10/17 | Word | |
| WC164 | Physician's Report of Workers' Compensation Injury | 01/19 | Word | |
| WC165 | Notice of DIME Negotiations | 10/18 | Word | |
| WC167 | Self-Insured PTD and Fatality Report | 12/18 | N/A | |
| WC168 | Notice of Change of Carrier or Adjusting Firm | 05/19 | Word | |
| WC169 | Sender's Transmission Profile | 07/02 | Word | |
| WC170 | Sender's Trading Partner Profile | 07/02 | Word | |
| WC171 | Third-Party Administrator Location List | 07/02 | Word | |
| WC172 | Trading Partner Insurer List | 07/02 | Word | |
| WC174 | Worker's Claim for Compensation Transmittal | 05/05 | Word | |
| WC175 | EDI Sender Acceptance Form | 07/02 | Word | |
| WC178 | Request/Notification for Follow-up IME | 04/23 | Word | |
| WC179 | Division IME Physician Summary Disclosure Form (Insurer or Self-Insured Employer) | 10/18 | Word | |
| WC180 | Removed as of 11/29/2022 | |||
| WC181 | Medical Billing Dispute Resolution Intake Form | 08/22 | Word | |
| Google Form | ||||
| WC188 | Authorized Treating Provider's Request for Prior Authorization | 12/21 | Word | |
| WC189 | Authorization for Release of Information | 03/23 | Word | |
| WC190 | Authorization for Release of Limited Information to Third Parties | 03/23 | Word | |
| WC191 | Voluntary Abandonment of Claim | 03/14 | Word | |
| WC192 | Motion to Close for Failure to Prosecute and Order to Show Cause | 04/19 | Word | |
| WC193 | Request for Disfigurement Award (Photo) | 07/18 | Word | |
| WC194 | Certificate of Mailing | 09/15 | N/A | |
| WC195 | Notification by an Authorized Treating Provider | 02/19 | Word | |
| WC196 | Rehabilitation Communication Form | 09/16 | Word | |
| WC197 | Request for Change of Physician | 06/16 | Word | |
| WC198 | Notice of Reschedule or Termination of the Division Independent Medical Examination (DIME) | 04/20 | Word | |
| WC199 | ||||
| WC200 | Notice of Agreement to Limit the Scope of the Division Independent Medical Examination (DIME) | 10/18 | Word | |
| WC201 | Division Independent Medical Examination (DIME) Report Template | 10/18 | Word | |
| WC202 | Application to the Colorado Uninsured Employer Fund | 09/23 | Word | |
| WC203 | Interpreter Invoice Form | 01/23 | Word | |
| WC204 | Colorado Uninsured Employer Fund Continuation Request | 08/23 | Word | |
| WCM3 | Permanent Work-Related Mental Impairment Rating Report Worksheet | 04/18 | Word | |
| WCM4 | Pharmacy Billing Statement - (Removed) | |||
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 |
||
|
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 | ||
|
Petition to Modify, Terminate, or |
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 |
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|
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. |
04/08 |
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|
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 |
||
|
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 |
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|
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 | 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 | 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 |
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| Instructions for WC134 | WC134A | Instructions for completing this form. | 10/20 | ||
|
Authorization for Release of Information |
WC189 |
This Division form serves as claimant authorization for release of workers' compensation documents. |
03/23 |
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|
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. |
03/23 |
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|
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. |
08/22 |
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|
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. |
08/22 |
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| 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 | 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. | 09/23 | Word | |
| Colorado Uninsured Employer Fund Continuation Request | WC204 | Claimants 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). | 08/23 | 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 |
||
|
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 | ||
|
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 | ||
|
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 | ||
|
Independent Medical Examiner's Summary Sheet |
WC132 |
This form is used by the Division Independent Medical Examiner to summarize his/her findings. |
01/20 |
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|
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 | ||
|
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 |
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|
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 | ||
|
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 | Word | ||
| Notice of Agreement to Limit the Scope of the Division Independent Medical Examination (DIME) | WC200 | 10/18 | Word | ||
| Division Independent Medical Examination (DIME) Report Template | WC201 | 10/18 | 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. |
|
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|
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 |
||
|
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 |
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|
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. |
|
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|
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. |
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|
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. |
|
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|
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. |
|
||
|
EDI Sender Acceptance |
WC175 |
This is an EDI form used by insurers in acceptance of the Colorado Electronic Data Interchange sender requirements. |
|
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|
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. |
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|
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 |
||
|
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 | ||
|
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 |
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|
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 |
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|
Request for Certification |
WC109 |
This form is used by employers to obtain certification status in the Colorado Workers' Compensation Premium Cost Containment Program. |
|
||
|
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 |
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| Google Form | |||||
|
Form |
# |
Description |
Revised |
Downloads |
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|
|
|
|
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 | ||
|
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. |
07/14 |
||
| 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 | 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. |
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|
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 |
||
|
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 | ||
|
Pharmacy Billing Statement |
WC-M4 Psych |
Removed |
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|
Form |
# |
Description |
Revised |
Downloads |
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|
| 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. |
08/22 |
|
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 |
||
|
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 |
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|
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 |
||
| 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 |
||
| Instructions for WC134 | WC134A | Instructions for completing this form. | 04/16 | ||
| Authorization for Release of Information | WC189 | This Division form serves as claimant authorization for release of workers' compensation documents. | 03/13 | 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 |
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|
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 | ||
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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 |
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|
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. |
06/23 |
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|
Surcharge |
WC113 |
This form is used by insurers to calculate applicable surcharge amounts. |
06/23 |
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|
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. |
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|
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). |
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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