DIVISION OF WORKERS’ COMPENSATION SETTLEMENT ROUTING SHEET
Customer Service 303.318.8700
Claimant’s name:
List all workers’ compensation (WC#) numbers
List all attorneys and corresponding registration numbers:
included in this settlement:
WC#:
DOI
Claimant’s Attorney Reg. #
WC#: DOI
Respondent’s Attorney Reg. #
WC#: DOI
Other Attorney Reg. #
WC#: DOI
Other Attorney
Reg. #
Type of settlement (check one): Total amount of settlement award (Include lump sum plus present value of any
Full and Final Settlement (F) structured settlement)
Partial Settlement (P)
$
Double check and verify the following – failure to do so could result in the rejection of your settlement agreement:
1. Workers’ compensation numbers are correct . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2. Claimant’s signature is properly notarized . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3. A standard order is included . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
I have reviewed the attached settlement document and order, and believe they comply with the Division rules.
Signature
Date
Print Name
Instructions for order return:
Pick up
Mail (addressed, stamped envelopes for all parties are attached)
Email:
Contact person for information:
Contact person for document pickup:
Name
Phone number
Name
Phone number
This form must be completed and submitted with the settlement document and order. Include a mailing certificate if the order is to be
mailed or electronically submitted. Submit the settlement document and copies for all parties listed on the mailing certificate. Failure to
correctly complete and submit all documents may result in rejection or return of the settlement. Settlement documents for claimants not
represented by an attorney must be submitted directly to the Prehearing Unit of the Division of Workers’ Compensation. Do not
complete this form if the claimant is unrepresented.
Division of Workers’ Compensation Use Only:
Approved Date:
By:
Rejected (see # ____ above) Date:
By:
Person picking up
documents:
Print Name Signature
On behalf of:
Date:
Mail or deliver all documents to:
Division of Workers’ Compensation, Customer Service
633 17th St., Suite 400, Denver, CO 80202-3626
cdle_dowc_settlements@state.co.us
WC105 Rev 03/14
