Fillable Compensation Dependents Notice and Claim for (Colorado DORA)

Fill Online, Printable, Fillable, Blank Compensation Dependents Notice and Claim for (Colorado DORA) Form

Use Fill to complete blank online COLORADO DORA pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Compensation Dependents Notice and Claim for (Colorado DORA)

On average this form takes 43 minutes to complete

The Compensation Dependents Notice and Claim for (Colorado DORA) form is 5 pages long and contains:

  • 0 signatures
  • 7 check-boxes
  • 170 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your DORA forms online.

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

BROWSE COLORADO DORA FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
1
Instructions for Completing the
Dependent’s Notice and Claim for
Compensation
Please read all pages
This form is “fillable.” That means you can type the information onto
the form from your computer and print the form. You will not be able
to save the form onto your computer’s hard drive.
When you open the form, click in the “Employee’s Name”
box (field), complete the information, and use the tab key to navigate
to the next field. Do not use the Enter
key; pressing the Enter key will
only page down. Each field has been limited. This means that you
cannot
continue to type information into a field if it doesn’t fit into the
space provided.
Use numbers only
to fill in the fields for Social Security Number, phone
number and dollar amounts. Do not use dashes, parentheses or
dollar signs; when you tab out of the field, it will fill in automatically. If
a dollar amount contains cents, do
type the period. To fill in a check
box, click inside the box with your mouse. Some fields contain a
drop down menu; click on the arrow and select one of the choices.
The injury description, witness information, incident description and
dependent information fields are surrounded by a grey border. Type
the information in the first field and tab to the next to enter more
information.
To clear or delete all the information you have typed onto the form,
click on the red “Clear Entire Form” button. To clear all information on
a single page, click on the red “Clear This Page” button. To change
the information in one field, use the backspace or delete key.
Go to Form
2
“Clear Entire Form” button
Clears all information at once
“Clear This Page” button
Clears all information on this page
“Check Box”
Click in box
“Drop Down Menu”
Click on the arrow for choices
3
“Grey Border Field”
Enter information in first field and tab to
the next field to enter more information
WC18 Rev 04/06 Page 1 of 3
COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT
DIVISION OF WORKERS’ COMPENSATION
DEPENDENT’S NOTICE AND CLAIM FOR COMPENSATION
Employee’s name (first, middle, last) Social Security # □ Male
□ Female
Employee’s home phone #
Division
Use Only
Employee’s street address City State Zip code SOI
Birth date Marital status Dependents Date of hire Occupation Employment status POB
/ /
□ Married
□ Single
□ Separated
□ Unknown
□ Yes
□ No
/ /
□ Full time
□ Other
□ Part time
□ Unknown
Employer’s name (Company)
Employer’s phone #
NOI
Employer’s mailing address City State Zip code Coder
Average Weekly Wage
A.
Calculate the average weekly wage. Multiply the average number of hours worked
per week, excluding overtime, times the hourly wage—see instructions
Subtotal (A) $
B.
Check box if employee received
Provide the average weekly value of the benefit
□ Overtime
$
□ Tips (amount reported to IRS)
$
□ Commissions
$
□ Piecework
$
□ Mileage (if a form of salary)
$
□ Other (room, board, etc.)
$
□ Health Insurance (see instructions)
$
Subtotal (B) $
C. Add subtotals A & B
=
Average weekly wage at time of injury (C) $
Date of injury/disease
/ /
(See instructions)
Date of death
/ /
Time employee began work
____ ____ □ a.m.
____ ____ □ p.m.
Injury time
____ ____ □ a.m.
____ ____ □ p.m.
□ Unknown
Last date worked
/ /
Date employer notified
/ /
Which part of body was affected?
What type of injury did the employee receive?
1
What was the employee doing just before the accident occurred?
2
How did the injury occur?
3
What object or substance directly harmed the employee?
4
Name and phone # of witness
( )
Where did the accident occur? (street address, city, state, and county) To whom was it reported?
Initial treatment (check one)
□ None □ Emergency room □ Hospital stay over 24 hrs □ Minor on-site □ Clinic/Hospital
Name and address of treating doctor or other health care professional
Name and address of facility where treated
If death resulted from an occupational disease (i.e.,silicosis, asbestosis, anthracosis, etc.) give names of employers where the exposure occurred and
dates of employment (attach additional sheet if needed).
/ / to / /
Dates of employment Employer
/ / to / /
Dates of employment Employer
For Division Use Only
FEIN Carrier claim #
Policy # Adjuster Code Block #
See instructions on reverse side
before completing form
Back to Instructions
Clear Entire Form
WC18 Rev 04/06 Page 2 of 3
1. Name of Mortuary Address
2. Amount of funeral expenses Has same been paid? If so, by whom?
3. Was employee married on the date of the injury?
□ Yes □ No
4. If married, provide:
a. Full name of surviving spouse
b. Present address and phone # of surviving spouse ( )
c. Was surviving spouse living with employee at the time of death?
□
Yes
□
No
d. Social Security # of spouse
e. Birth date of spouse
/ /
5. Was employee previously married?
□ Yes □ No
If so, provide name and address of former spouse(s)
6. Provide name, date of birth, SS #, and present address of all children of the employee under the age of eighteen (18) years:
Name Date of Birth SS # Address
/ /
/ /
/ /
/ /
7. Provide name, date of birth, SS #, and present address of any child of the employee over the age of eighteen (18) and under the age
of twenty-one (21)who was dependent upon the employee for support and was a full-time student at an accredited school at the time
of employee’s death:
Name Date of Birth SS # Address
/ /
/ /
8.
Provide name, date of birth, SS #, present occupation, relationship to the employee and present address of any other person who
was wholly or partially supported by the employee at the time of employee’s death:
Name Date of Birth SS # Occupation
Relationship
to Employee
Present Address
/ /
/ /
Other than amounts received from the employee, what income did each of the dependents listed in #8 receive, during the year
9.
immediately preceding the death of the employee?
Indicate whether each of the dependents listed in #8 was incapable or actually disabled from earning his/her own living, and if so,
10
.
for what period of time.
Attach a copy of employee’s marriage certificate(s), death certificate, and children’s birth certificates.
State of Colorado,
{
ss.
County of
Affidavit of Claimant
being first duly sworn upon oath deposes and says, that the statements made in the
foregoing notice and claim are true.
(Signature of claimant or person making claim in his, her or their behalf)
Subscribed and sworn to before me this day of , .
My commission expires ,
(Notary Public in and for said County and State aforesaid.)
WC18 Rev 04/06 Page 3 of 3
CALCULATION OF AVERAGE WEEKLY WAGE
To determine the weekly wage, calculate the following:
• First, calculate the employee’s average weekly wage. Multiply the average number of hours worked per week (excluding overtime) times the
hourly wage. If the employee was paid by the month, multiply the monthly salary times 12 (months) and divide by 52 (weeks). If the employee
was paid bi-weekly (every other week), take the bi-weekly salary and divide by 2. If the employee was paid on a per diem basis, multiply the daily
wage times the number of days and fractions of days in the week s/he would have worked under the contract of hire if the injury had not occurred.
• Next, determine the average weekly amount of any overtime, tips (as reported to the IRS), commissions, piecework (average weekly value can be
calculated by taking the total amount earned with the employer in the 12 months immediately preceding the injury and dividing that amount by the
number of weeks, and fractions of weeks worked). If mileage was a form of salary, take the average earned per week in the 60 days immediately
preceding the injury.
• Add the average weekly value of any board, rent, housing or lodging, etc., provided by the employer.
• If you, the dependent, were covered by group health insurance through this employment, add your cost of converting to a similar or lesser
insurance plan and include this cost in the average weekly wage computation.
• Add the totals from each of the above categories to obtain the average weekly wage and insert in Average weekly wage at time of injury field.
DATE OF INJURY/DISEASE
Always include a date of injury. In the case of an occupational disease, use the date the employee was last exposed to the hazard.
INJURY DESCRIPTION
1 Be specific. Examples: “heart attack”; “chemical exposure”, etc.
2 Describe the activity, as well as the tools, equipment or material the employee was using. Be specific. Examples: “climbing a ladder
while carrying roofing materials”; “spraying chlorine from hand sprayer,” etc.
3 Tell us how the injury occurred. Examples: “When ladder slipped on wet floor, employee fell 20 feet”; “Employee was sprayed with
chlorine when gasket broke during replacement,” etc.
4 Examples: “concrete floor”; “chlorine”; “radial arm saw”, “beryllium.”
FILING AND BENEFIT INFORMATION
Upon completion, mail or deliver two (2) copies of the Dependent’s Notice and Claim for Compensation to: The Colorado Division of
Workers’ Compensation, Customer Service Unit, 633 17
th
St., Suite 400, Denver, CO 80202-3626. In order to obtain information on
benefits and dispute resolution options, or to request a copy of the Employee’s Guide, please contact our Customer Service Unit at (303)
318.8700 or toll free at (888) 390.7936 for English, or (800) 685.0891 for Spanish. You may also visit our website at
www.coworkforce.com/DWC/
GENERAL INFORMATION
When your claim form is received by the Division of Workers’ Compensation, a copy will be sent to the employer’s insurance carrier
(insurer). The insurer has 20 days from receipt of this information to advise, in writing, whether liability will be admitted or denied, that is,
whether it accepts responsibility for payment of related medical, funeral and/or dependent’s benefits. If the insurer denies liability or fails to
respond within the prescribed time frame, you have the right to request a formal hearing and have the issue decided by an Administrative
Law Judge at the Division of Administrative Hearings.
When a person is fatally injured on the job, workers' compensation provides weekly payments to the surviving dependent(s) and up to $7,000
for funeral expenses. The weekly amount of dependent’s benefits is calculated at two thirds of the employee’s average weekly wage at the
time of injury and is subject to maximum and minimum benefit rates. Payments are made for the lifetime of a dependent spouse, or until
remarriage. If a surviving spouse remarries and there are no dependent children, a lump sum equal to two years of benefits will be paid (less
any previous lump sum payments or overpayments). If there are dependent children, the spouse's benefits are reapportioned among the
remaining dependents. Any dependent child (including one to whom child support was paid or owed) may be eligible for payments until age
eighteen (18), or until age twenty-one (21) if the child is a full-time student. If there is no spouse or dependent child, other relatives such as a
parent, grandparent, sister or brother, may be eligible for partial benefits. These partial benefits are paid for six years. And finally, if the
deceased is under the age of twenty-one (21) with no dependants, payment of $15,000 is payable to the parents of the deceased. All of these
benefits are reduced by 50 percent of the death benefits received by the dependents through social security.
For additional information on the provisions of the Colorado workers’ compensation system, you may contact the Customer Service Unit of
the Colorado Division of Workers’ Compensation at (303) 318.8700, or toll free at (888) 390.7936.
NOTICES
You are hereby notified that if a child support obligation is owed, compensation benefits may be attached and payment of the child support
obligation may be withheld and forwarded to the obligee pursuant to sections 8-42-124 and 26-13-122(4), C.R.S. YOU ARE FURTHER
NOTIFIED that you must provide written notice of any award for social security, pension, disability or other source of income that might
reduce your compensation benefits. This notice must be sent to the insurance carrier or self-insured employer within 20 days after learning
of the payment or award. Failure to report may result in suspension of your benefits pursuant to section 8-42-113.5, C.R.S.
C.R.S. Section 10-1-128(6) (a) states: “It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an
insurance company for the purposes of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial
of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or
misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or
claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance
within the department of regulatory agencies.”
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Compensation Dependents Notice and Claim for (Colorado DORA)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 27 January 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document