Fillable First Report Transmittal (Colorado DORA)

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First Report Transmittal (Colorado DORA)

On average this form takes 22 minutes to complete

The First Report Transmittal (Colorado DORA) form is 3 pages long and contains:

  • 0 signatures
  • 3 check-boxes
  • 85 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
First Report Transmittal
Please read all pages
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WC 106 Rev. 05/05
COLORADO DIVISION OF WORKERS’ COMPENSATION
FIRST REPORT TRANSMITTAL
Submitted By:
Company Name: ______________________________________________
Block # or Adjustor Code: _______________________________________
Check One
___ Adjusting Firm
___ Carrier
___ Self-Insured
Phone # _________________
Fax # ___________________
Mailing Address: ______________________________________________
______________________________________________
______________________________________________
______________________________________________
Submitted On Behalf Of: (if submitted by Adjusting Firm)
Carrier Name __________________________________________
Carrier Block #_________
Carrier Claim # Employer Name Claimant Name
WC#
Division Assigned
Transmittal Page _______ of _____ pages. Number of First Reports Attached ______
SEE INSTRUCTIONS ON REVERSE SIDE
Clear Entire Form
Back to Instructions
WC 106 Rev. 05/05
INSTRUCTIONS
The First Report Transmittal Form (Transmittal) is used by the carrier or adjusting firm to submit Employers
First Reports of Injury (FROI). The Transmittal will be returned via fax noting the Workers’ Compensation
number (WC#) assigned by the Division. This WC# must be listed on all future documents relating to the claim.
The Transmittal MUST be placed on top of the FROIs. List the FROIs on the Transmittal in Carrier Claim
Number order.
Use one transmittal per carrier. Do not combine carriers on a transmittal.
Company Name: List the name of the adjusting firm, carrier, or self-insured submitting the form.
Check One: Check the box that identifies the type of entity submitting the form.
Block # or Adjustor Code: If the type of entity submitting the transmittal is a carrier or self-insured, list the
block # that identifies the carrier or self-insured. If the type of entity submitting the transmittal is an adjusting
firm, list the adjustor code.
Mailing Address: List the mailing address of the adjusting firm, carrier, or self-insured submitting the form.
Phone #: List the telephone number of the adjusting firm, carrier, or self-insured submitting the form.
Fax #: List the Fax number of the adjusting firm, carrier, or self-insured submitting the form.
Carrier Name: If an adjusting firm submits the transmittal, list the name of the carrier or self-insured
associated with the attached FROIs.
Carrier Block #: If an adjusting firm submits the transmittal, list the block number assigned to the carrier or
self-insured associated with the attached FROIs.
Carrier Claim #: List the claim number assigned by the carrier or self-insured.
Employer Name: List the name of the employer associated with the claim.
Claimant’s Name: List the name of the claimant.
WC#, Division Assigned: Do not complete. The Division will assign the Workers’ Compensation number.
Transmittal Page __ of __ pages: List the page number of the transmittal and the number of total transmittal
pages.
Number of First Reports Attached: List the number of FROIs attached to the transmittal.
Mail or Deliver to:
Division of Workers' Compensation
633 17th St., Suite 400
Denver, CO 80202-3660
303.318.8700
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First Report Transmittal (Colorado DORA)

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Completed 27 January 2021

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