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
an
de
endents currentl
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
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
of
:
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
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