Fillable REQUEST FOR LUMP SUM PAYMENT (Permanent Partial, Permanent (Colorado DORA)

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REQUEST FOR LUMP SUM PAYMENT (Permanent Partial, Permanent (Colorado DORA)

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COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT
DIVISION OF WORKERS’ COMPENSATION
REQUEST FOR LUMP SUM PAYMENT
(Permanent Partial, Permanent Total and Dependents’ Benefits)
Claimant W.C. #
Date of Injury Employer
Insurance Carrier Insurance Carrier Claim #
Insurance Carrier/TPA Address
Street City State Zip Code
CHECK THE APPROPRIATE BOX:
I am represented and request a lump sum payment*
I am not represented and request a lump sum payment (to be calculated and ordered by the Division of Workers’
Compensation.)
* the lump sum, less discount, will be calculated and paid by the insurance carrier
FAILURE TO SIGN THE APPLICATION MAY DELAY PROCESSING OF YOUR REQUEST.
NOTE: A lump sum payment cannot be granted until SIX (6) MONTHS have elapsed from the date of injury or death, and
there has been a final award of permanent benefits.
1. Name of applicant: Phone #: ( )
Address
Street City State Zip Code
2. Date of applicant’s birth:
3. If applicant is other than claimant, state family relationship:
4. The disability or death benefit award is the result of a:
Final Admission
Final Order
5. Date of disability or death benefit award:
month day year
6. Amount requested $
7. Applicant is presently:
Receiving Social Security
Benefits: Monthly Amount $
Receiving pension benefits or other i
ncome: Monthly Amount $
Check the box that applies:
I accept the amount of permanent partial or permanent total disability benefits if so awarded. I understand
that in accordance with section 8-43-406 of the Colorado Workers’ Compensation Act, a four percent per
annum discount is subtracted from the total award.
I accept the award of death benefits. I understand that in accordance with section 8-43-406 of the Colorado
Workers’ Compensation Act, a four percent per annum discount is subtracted from the total award.
Dated this day of , .
day month year
Applicant’s Signature
COMPLETE, SIGN AND DELIVER OR MAIL ONE COPY OF THIS FORM TO THE INSURANCE
CARRIER HANDLING YOUR CLAIM AND ONE COPY TO THE DIVISION OF WORKERS’
COMPENSATION
WC62 Rev. 07/14
Page 1 of 3
Clear Entire Form
Clear This Page
COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT
DIVISION OF WORKERS’ COMPENSATION
LUMP SUM CALCULATION AND PROOF OF PAYMENT
FOR PERMANENT PARTIAL DISABILITY CLAIMS
Claimant: WC#:
Insurance Adjuster: Please complete this form within 10 business days of the mailing date of the claimant’s request for a lump sum
payment. A copy should be sent to the claimant attorney if represented. Check the applicable box:
The insurance carrier has calculated and paid a lump sum and is confirming payment (Complete entire form)
The insurance carrier is submitting figures to the Division to calculate a lump sum (Complete Parts A, C & D)
OBJECTION TO LUMP SUM: The insurance carrier objects to the payment of a lump sum based on the following:
Part A: Calculation (REQUIRED)
1.
Total award for permanent partial disability (PPD), if applicable:
#1 $
2. Has a previous lump sum been paid? No Yes
If so, what is the aggregate of all lum
p sums paid?
#2
$
Provide the date of the last PPD pay
m
ent:
/ /
3. Is there an overpayment to be credited? No Yes If so, what is the amount? #3 $
4. Amount of permanent partial disability payments made to date: #4 $
5.
Total of the amounts paid from #2 + #3 + #4 = Amount of #5
#5 $
6.
PPD balance due: (#1 minus #5)
#6 $
Part B: Confirmation of Payment (forward the completed form to all parties within 10 business days from date of the request)
1. Date of Payment: / / Amount of payment: $
2. Lump sum discount applied (attach the discount calculation) $
3. Is there a PPD balance remaining? No Yes If yes, amount: $
Part C: Adjuster Information (REQUIRED)
Adjuster: Phone: ( )
Insurance Carrier or
3
r
d
Party Administrator
Fax #: ( )
Address:
Part D: Certificate of Mailing (REQUIRED): Copies of this document were placed in U.S. mail or delivered to the following
parties this
day of , by:
day month year
Insurance Ad
j
uster or Re
p
resentative
List names and addresses of all persons copied:
Claimant:
Claimant Attorney:
Respondent Attorney:
Division of Workers’ Compensation, 633 17
th
St., Suite 400, Denver, CO 80202-3626
Notice to Applicant: If you object to this response, notify the Division of Workers’ Compensation in writing of your objection
within 10 (ten) business days from the certificate of mailing date. Mail this objection to the Division of Workers’
Compensation, 633 17
th
St., Suite 400, Denver, CO 80202-3626.
Block # Adj. Code
WC62 Rev. 07/14 Page 2 of 3
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0
COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT
DIVISION OF WORKERS’ COMPENSATION
LUMP SUM CALCULATION AND PROOF OF PAYMENT
FOR PERMANENT TOTAL AND FATAL CLAIMS
Claimant: WC#:
Insurance Adjuster: Please complete this form within 10 business days of the mailing date of the claimant’s request for a lump sum
payment. A copy should be sent to the claimant attorney if represented. Check the applicable box:
The insurance carrier has calculated and paid a lump sum and is confirming payment (Complete entire form)
The insurance carrier is submitting figures to the Division to calculate a lump sum (Complete Parts A, C & D)
OBJECTION TO LUMP SUM: The insurance carrier objects to the payment of a lump sum based on the following:
TYPE OF AWARD – CHECK ONE:
PTD (permanent total disability) Fatal (dependent’s benefits)
Part A: Calculation (REQUIRED)
1. Lump Sum amount requested: $
Birthdate of the claimant and (for fatal claims) dependent(s):
/ /
(if additional space is needed, please attach a separate page)
/ /
For fatal benefits, identif
y
an
y
de
p
endents currentl
y
in school:
(if additional space is needed, please attach a separate page)
2.
Have any previous lump sums been paid?
No Yes
If so, what is the total of all lump sums paid for this claimant?
$
3. What is the weekly benefit rate? $
Part B: Confirmation of Payment (forward the completed form to all parties within 10 business days from date of the request)
All Permanent Total and Fatal claims must have a new admission when the weekly benefit rate changes. Attach discount calculations.
1. Date of Payment
/ /
Amount of payment: $
2. Cost of the Lump Sum per week (to be recovered over the life of the claim) $
3. New weekly payout rate: $
Part C: Adjuster Information (REQUIRED)
Adjuster: Phone: ( )
Insurance Carrier o
3
r
d
Party Administrator
Fax #: ( )
Address:
Part D: Certificate of Mailing (REQUIRED): Copies of this document were placed in U.S. mail or delivered to the following
parties this
da
y
of
,
by
:
day month year
Insurance Adjuster or Representative
List names and addresses of all persons copied:
Claimant:
Claimant Attorney:
Respondent Attorney:
Division of Workers’ Compensation, 633 17
th
St., Suite 400, Denver, CO 80202-3626
Notice to Applicant: If you object to this response, notify the Division of Workers’ Compensation in writing of your objection
within 10 (ten) business days from the certificate of mailing date. Mail this objection to the Division of Workers’
Compensation, 633 17
th
St., Suite 400, Denver, CO 80202-3626.
Block # Adj. Code
WC62 Rev. 07/14
Page 3 of 3
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REQUEST FOR LUMP SUM PAYMENT (Permanent Partial, Permanent (Colorado DORA)

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Completed 27 January 2021

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