Fillable Fatal General Admission (Colorado DORA)

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Fatal General Admission (Colorado DORA)

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The Fatal General Admission (Colorado DORA) form is 4 pages long and contains:

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  • 5 check-boxes
  • 88 other fields

Country of origin: US
File type: PDF

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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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1
Instructions for Completing the
Fatal General Admission
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
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to save the form onto your computer’s hard drive.
When you open the form, click in the “Workers’ Compensation WC #”
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
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Use numbers only
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Block # Adj. Code
WC151 Rev 05/05 Page 1 of 2
FATAL CASE - GENERAL ADMISSION
Workers’ Compensation (WC) # ___________________________
Deceased’s Name ______________________________________
Deceased’s Social Security # _____________________________
Date of Injury_________________________________________
Insurance Carrier ______________________________________
Third Party Administrator ________________________________
Carrier Claim # ___________________________________________
Average Weekly Wage _____________________________________
Date of Death _____________________________________________
Weekly Compensation Rate __________________________________
Employer ________________________________________________
NOTICE TO CLAIMANT
This is an important legal document that can affect your rights. If you disagree with the amount or type of benefits which the
carrier has agreed to pay, you may write a letter to the Division of Workers’ Compensation, 633 17th Street, Suite 400, Denver,
CO 80202-3660, stating that you object to this admission. Please send a copy to the insurance carrier or self-insured employer.
See page 2 for other important notices.
Liability is admitted for the following benefits: Medical Benefits Safety Rule Violation
Funeral Expenses $ ___________________ Offset (Attach Calculation)
Complete the following for each known dependent: (Attach additional pages, if needed)
Attending School Whole or Partial
Name Birth Date Yes or No Relationship Dependency(W or P)
If no dependents, has payment been made to the Subsequent Injury Fund (SIF)? Yes No
Remarks: (Attach additional pages, if needed)
BENEFIT HISTORY - Dependents= benefits (past and present) are admitted for the following:
Name Time Periods Weeks Rate per Week Totals
__________________________________________ __________through _________ = ______ x $ ____________ = $______________
__________________________________________ __________through _________ = ______ x $ ____________ = $______________
__________________________________________ __________through _________ = ______ x $ ____________ = $______________
__________________________________________ __________through _________ = ______ x $ ____________ = $______________
__________________________________________ __________through _________ = ______ x $ ____________ = $______________
__________________________________________ __________through _________ = ______ x $ ____________ = $______________
The above time periods include the dates specified. Amount of Interest Paid $ ___________________________
Amount of Penalties Paid $ __________________________
(Attach additional pages, if needed) Amount Overpaid $ ______________________(See Remarks)
Claims Representative ________________________________ Phone# ____________________ Toll-Free Phone # __________________
Address: ________________________________________________________________________________________________________
CERTIFICATE OF MAILING: Copies of this document were placed in the U.S. mail or delivered to the following parties
this _________ day of ______________________________, __________.
List names and addresses of all persons copied: Name Address
Dependent(s):
Dependents’ Attorney(s):
Employer:
Carrier’s Attorney:
Other:
Division of Workers’ Compensation, 633 17th Street, Denver, CO 80202-3660
By: __________________________________________________________________
Clear Entire Form
Back to Instructions
WC151 Rev 05/05 Page 2 of 2
(The top portion of this side may be used for mailing address)
FATAL CASE - GENERAL ADMISSION
IMPORTANT: SEE NOTICE TO CLAIMANT SECTION ON THE OTHER SIDE OF THIS FORM
OTHER NOTICES TO CLAIMANT:
YOU ARE HEREBY NOTIFIED that the insurance carrier or self-insured employer admits that the fatality reported
herein is compensable. YOU ARE ALSO 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 C.R.S. section 8-42-124 and C.R.S. section 26-13-122(4). 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 C.R.S.
section 8-42-113.5.
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Fatal General Admission (Colorado DORA)

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Completed 27 January 2021

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