Fillable COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT Division of (Colorado DORA)

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COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT Division of (Colorado DORA)

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Colorado Department of Regulatory Agencies (DORA) is responsible for professional licensing and consumer protection in Colorado USA.

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COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT
Division of Workers’ Compensation
633 17
th
Street, Suite 400
Denver, CO 80202-3660
Phone: (303) 318-8700 | Toll Free: (888) 390-7936
Fax: (303) 318-8710
AUTHORIZATION FOR RELEASE OF LIMITED INFORMATION TO THIRD PARTIES
Claimant Social Security Number:
Claimant Name:
Requestor (Third Party) Name:
Employer Business Name:
The above referenced claimant authorizes limited access to above-mentioned requestor to all workers’ compensation
files on record as stated below. This authorization shall remain in effect for ninety days from the date of claimant’s
signature, unless claimant notifies the Division of Workers’ Compensation in writing before such time, that claimant
is revoking said authorization.
Information provided shall be limited to:
Workers’ Compensation Number
Date of Injury
Part of Body
Employer
Claimant’s Signature (in presence of notary) Date Signed (to be completed by claimant)
Authori
z
ation must be signed and dated by the claimant.
Notariz
a
tion is required.
STATE OF
When using an embossed seal, please shade before faxing.
COUNTY OF
Subscribed and sworn to before me this
day of , 20
by
(Print name of claimant) Place notary seal here
Signature of Notary Public
My commission expires:
Altered forms will not be accepted.
WC 190 Rev. 06/18
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COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT Division of (Colorado DORA)

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Completed 27 January 2021

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