Fillable Social Security # Date of Injury Insurer Claim (Colorado DORA)

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Social Security # Date of Injury Insurer Claim (Colorado DORA)

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WC74 Rev 09/18
COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT
DIVISION OF WORKERS’ COMPENSATION
NOTICE OF CONTEST
Pursuant to Section 8-43-203, C.R.S., the undersigned employer or insurance carrier hereby notifies the claimant and the
Division of Workers’ Compensation that liability for the above-referenced claim is contested/denied for the following
reason:
Further Investigation for
Injury/Illness Not Work-Related
No Insurance Coverage
Third-Party Involvement
Other (please describe)
NOTICE TO CLAIMANT:
You may request an expedited hearing on the issue of compensability by filing an Application for Hearing and Notice
to S
et and a Request for Expedited Hearing with the Office of Administrative Courts. These forms must be filed
within 45 days from the date of mailing on this Notice of Contest. If you don’t file within 45 days, the hearing will be set
within the usual time limits. You may call the Office of Administrative Courts in Denver at 303.866.2000, in Grand
Junction at 970.248.7340, or in Colorado Springs at 719.576.2958, to obtain the forms.
Claim Representative ________________________________________________ Phone # (_____)_________
Address _____________________________________________________________________________________
CERTIFICATE OF MAILING: Copies of this document were placed in the U.S. mail or delivered to the following
parties this _________ day of ______________________________, __________.
List names and ad
dresses of all persons copied:
Claimant:
Claimant’s Attorney:
Employer:
Carrier’s Attorney:
Division of Workers’ Compensation: (Only electronic filing accepted.)
By: ___________________________________________________________________
Block #
Adj. Code
TO:
WC #
Social Security #
Date of Injury
Insurer Claim #
Insurer Name
Employer Name
Claimant's Name
Claimant's Address
Claimant's Address
and
DIVISION OF WORKERS' COMPENSATION
INSTRUCTIONS / DEFINITIONS
Type or print legibly.
TO: List the name and address of the injured worker to whom the Notice of Contest is mailed.
WC#: List the Workers’ Compensation number assigned by the Division to the claim.
Social Security #: List the Social Security number of the claimant.
Date of Injury: List the date of injury associated with the claim.
Insurer Claim #: List the claim number assigned by the carrier or self-insured to the claim.
Insurer Name: List the name of the carrier or self-insured associated with the claim.
Employer Name: List the name of the employer associated with the claim.
Reason for Contesting Claim: Check only ONE reason for contesting the claim. If “Further Investigation”
is checked, list the reason for the investigation. If “No Insurance Coverage” is checked, a reason can be listed.
Use “Other” only if a listed option does not apply. If “Other” is checked, include a description.
Claim Representative: List the name of the individual claim adjuster who manages the claim.
Phone #: List the telephone number, including area code, of the claim representative.
Address: List the mailing address of the claim representative.
Certificate of Mailing Date: List the day, month, and year that this Notice of Contest was placed in the U.S.
mail or delivered to the claimant and other parties. The date mailed and the date the form is completed are not
always the same date.
Names and Addresses: List the name and mailing address of each party to the claim to whom this Notice of
Contest was mailed or delivered. Space is provided for the claimant, claimant’s attorney, employer, carrier’s
attorney, and the Division of Workers’ Compensation. Complete name and address as appropriate.
The Division’s copy of the Notice(s) of Contest is required to be filed electronically. All other parties’ copies
must be mailed.
By: The claim representative completing the form must sign the form as a representative of the carrier or self-
insured attesting to the validity of the certification date.
Block #: List the block number assigned to the carrier or self-insured associated with the claim.
Adj. Code: If applicable, list the adjuster code assigned to the third party administrator adjusting the claim.
Division of Workers' Compensation
633 17th St., Suite 400
Denver, CO 80202-3626
303.318.8700
WC74 Rev 09/18
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Social Security Date of Injury Insurer Claim (Colorado DORA)

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Completed 27 January 2021

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