Fillable Request for Services DEPARTMENT OF LABOR AND EMPLOYMENT (Colorado DORA)

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Request for Services DEPARTMENT OF LABOR AND EMPLOYMENT (Colorado DORA)

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The Request for Services DEPARTMENT OF LABOR AND EMPLOYMENT (Colorado DORA) form is 1 page long and contains:

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  • 16 check-boxes
  • 30 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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DEPARTMENT OF LABOR AND EMPLOYMENT
DIVISION OF WORKERS' COMPENSATION
633 17
th
Street, 4
th
Floor
Denver, CO 80202-3626
(303) 318-8700
Request for Services
Service Requested:
DOWC Use Only
Examine Records
Copy Complete File
LOC
PGS
Copy Paper Clipped Pages Only
Certified Copy
Other:
_______________________________________________
Authority to this information:
A Party to W.C. #:
______________________________________
a. Employer
b. Insurance Carrier
c. Claimant
Name of Requesting Attorney:
______________________________________
Note: Dates of injury after July 1, 1989 require a Division notarized authorization signed by the claimant, for all non-party requestors.
Billing Information
Job #:
____________________________________
Invoice #: ______________________
DOWC Use Only
Contact:
____________________________________
Phone #: ( ) ________________ Ext. _______
Agency:
____________________________________
Fax #: ( ) _________________
Address:
____________________________________
JOB: Mail
Received By: _________________________________
Date: _______________________________________
DOWC Use Only
Quantity
Item
Unit Cost
Total Cost
By
Date
Copy
$0.25
Approved
Rush
$0.50
Copied
Certified Copy
$2.00
Contacted
Posted
Postage
TOTAL
SUBMIT COMPLETED FORM TO: cdle_dowc_rfs@state.co.us
WC134 Rev 04/20
DO NOT PRINT/MAIL
Email
$5.00
Pickup Rush
Email
Email:
____________________________________
____________________________________
____________________________________
Date: ________________________________
SSN: ________________________________________
Claimant Name: _________________________________________________________________________________
W.C. #
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Request for Services DEPARTMENT OF LABOR AND EMPLOYMENT (Colorado DORA)

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Completed 27 January 2021

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