Fillable REQUEST FOR DISFIGUREMENT (Colorado DORA)

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REQUEST FOR DISFIGUREMENT (Colorado DORA)

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The REQUEST FOR DISFIGUREMENT (Colorado DORA) form is 2 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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STATE OF COLORADO
Division of Workers’ Compensation
WC Number:
IN THE MATTER OF THE CLAIM OF
Claimant
REQUEST FOR DISFIGUREMENT
AWARD (PHOTO)
v.
Employer,
and
Insurer,
Respondents.
I was injured as the result of an industrial injury or occupational disease that occurred on
, , .
month day year
I have a serious permanent disfigurement to an area of my body normally exposed to public view.
The disfigurement is to my .
list part or parts of body that are normally exposed to public view
The injury occurred at least six months ago, or my authorized treating physician has placed me at
maximum medical improvement. I have attached photographs that clearly show the
disfigurement, a photograph of my face for identification purposes and have dated and
signed the back of each photograph.
Signed: Dated:
Signature of Claimant
Print Name: Phone:
Address:
A copy of this completed form and a copy of the photographs must be delivered or mailed to the
Respondent-Insurer. The original form with photographs and any other attachments should be
delivered or mailed to the Division of Workers’ Compensation.
WC193 Rev. 07/18
Page 1
Clear Entire Form
CERTIFICATE OF MAILING OR DELIVERY:
Copies of this document, Request for Disfigurement Award, were placed in the U.S. mail or
delivered to the following parties this day of , .
day month year
List names and addresses of all parties copied:
Employer:
Carrier:
Carrier’s Attorney:
Division of Workers’ Compensation, 633 17
t
h
Street, Suite 400, Denver, CO 80202
By:
Signature
WC193 Rev. 07/18 Page 2
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REQUEST FOR DISFIGUREMENT (Colorado DORA)

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Completed 27 January 2021

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