Fillable General Admission of Liability (Colorado DORA)

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General Admission of Liability (Colorado DORA)

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The General Admission of Liability (Colorado DORA) form is 3 pages long and contains:

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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
General Admission of Liability
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 “Claimant’s Name” box (field),
complete the information, and use the tab key to navigate to the next
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2
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WC2 Rev 07/14
PLEASE READ REVERSE SIDE
Block # Adj. Code
COLORADO DEPARTMENT OF LABOR & EMPLOYMENT
DIVISION OF WORKERS’ COMPENSATION
GENERAL ADMISSION OF LIABILITY
WC #
Carrier #
TO:
Soc. Sec. #
Claimant’s Name
Employer
Date of Injury
Claimant’s Address
Average Weekly Wage
Date first payment paid TTD
and Date first payment PPD
DIVISION OF WORKERS’ COMPENSATION Date of MMI
YOU ARE HEREBY NOTIFIED that the insurance carrier or self-insured employer (named below) admits that the injury or
occupational disease 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 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.
Liability is admitted for the following benefits: See Reverse Side for Codes
Safety Rule Violation
medical benefi
ts Offset Attach Calculation
tem
porary total disability Amount of Inte
rest Paid $
temporary partial disability Amount of Penalties Paid $
rehabilitation maintenance benefits
Working unit % Disability Age
disfigurement 1. Schedule Injury % (part of body)
permanent partial disability 2. Schedule Injury % (part of body)
Complete the following if admitting for disability
Type of Benefit Time Periods Rate per Week Totals
thru = wks $ $
thru = wks
$ $
thru = wks $ $
thru = wks $ $
thru = wks $ $
thru = wks $ $
thru = wks $ $
The above time periods represent inclusive dates.
Remarks:
Carrier or Self-Insured
Address
Telephone No.
NOTICE TO CLAIMANT: 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 ST., SUITE 400,
DENVER, CO 80202-3660, STATING THAT YOU OBJECT TO
THIS ADMISSION OF LIABILITY.
By:
Adjuster or Claims Representative
Copies of this admission were mailed this day of
,
to:
Claimant’s Attorney Employer Division of Workers’ Compensation Respondent’s Attorney Claimant
Clear Entire Form
Back to Instructions
WC2 Rev.
07/14
BENEFITS
Compensation benefits are paid by insurance carriers for compensable injuries. Temporary disability benefits are paid every 2
weeks.
Temporary Total Disability - Total disability of more than 3 working days. If disability lasts for more than 14 calendar days,
compensation shall be paid from the day left work. Compensation is payable at the rate of 66 2/3% average weekly wage in
effect at the time the injury/exposure not to exceed the statutory maximum. A loss of fringe benefits specifically enumerated in
the statute should be included in the calculation of the average weekly wage.
Permanent Partial Disability - Payable where there is residual impairment, based upon the part of the body affected, or on the
extent of medical impairment.
Facial or Bodily Disfigurement – Payable for serious, permanent disfigurement about the head, face, or parts of the body
normally exposed to public view. The maximum benefit is established each year for injuries that occur during that year. In
addition, for injuries that occurred on or after July 1, 2007, it is possible to receive a larger amount for extensive
disfigurement. Information regarding the maximum benefit for your date of injury is located on the Division’s website, or you
may contact the Customer Service Unit at (303) 318-8700.
Medical Benefits - Current medical benefits for medical, hospital and surgical supplies, prescriptions, crutches, apparatus and
vocational rehabilitation.
Temporary Partial Disability - Temporary partial disability of more than 3 working days. Compensation is payable at the rate
of
66 2/3% of the difference between the employee’s average weekly wage at the time of injury and said employee’s average
weekly wage during the continuance of the temporary partial disability not to exceed a maximum of 91% of the state average
weekly wage per week.
MMI - Maximum Medical Improvement means a point in time where any medically determinable physical or mental
impairment as a result of injury has become stable and when no further treatment is reasonably expected to improve the
condition.
Codes for scheduled ratings:
01 Arm @ Shoulder
03 Hand @ Wrist
04 Thumb @Metacarpal
05 Thumb @ Proximal
06 Thumb @ Distal
07 Index @ Metacarpal
08 Index @ Proximal
09 Index @ Second
10 Index @ Distal
11 Middle @ Metacarpal
12 Middle @ Proximal
13 Middle @ Second
14 Middle @ Distal
15 Ring @ Metacarpal
16 Ring @ Proximal
17 Ring @ Second
18 Ring @ Distal
19 Little @ Metacarpal
20 Little @ Proximal
21 Little @ Second
22 Little @ Distal
2
3 Leg @ Hip
25 Leg @ Foot, Heel, Ankle
26 Great Toe @ Metatarsal
27 Great Toe @ Proximal
28 Great Toe @ Distal
29 Other Toe @ Metatarsal
30 Other Toe @ Proximal
31 Other Toe @ Distal
32 Loss of a Tooth
33 Blindness One Eye
34 Deafness Both Ears
35 Deafness One Ear
36 Total Hearing 2nd Ear
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General Admission of Liability (Colorado DORA)

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Completed 27 January 2021

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