Fillable Voluntary Abandonment of Claim Date of Injury: Carrier (Colorado DORA)

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Voluntary Abandonment of Claim Date of Injury: Carrier (Colorado DORA)

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WC191 Rev 03/14
COLORADO DEPARTMENT
OF LABOR & EMPLOYMENT
Division of Workers’ Compensation
633 17th Street, Suite 400
Denver, CO 80202
Voluntary Abandonment of Claim
Claimant Name: Workers’ Compensation No.
Date of Injury: Carrier Claim No.
Insurance Carrier: Employer:
I am voluntarily abandoning all future entitlements to the above captioned workers’ compensation
claim by completing this form.
I understand that by completing this form I am waiving any future benefits to which I may be
entitled, including :
Payment for time lost from work, and;
Payment for any permanent impairment, and;
Payment for disfigurement.
I understand that by completing this form I am waiving entitlement to any current and future
medical benefits, including reimbursement of mileage to and from related medical treatment.
I understand that I may request that this claim be reopened, but only within a limited time, and only
for limited reasons, including a change in medical condition. If the insurance company or the
employer objects to my request to reopen, the issue will be decided by a judge at a hearing.
I understand that a Final Admission of Liability will be filed and my claim will be closed if I do not
object to the Final Admission of Liability.
I have not been offered anything of value in exchange for waiving these rights and for completing
this form.
Signature of Claimant Print Name Date
For use by a language interpreter, if necessary: I, (print name of interpreter)
affirm that on this
day of
, , I read this document in its entirety to the
individual whose name appears above in that person’s native language, and that the person indicated an understanding
of each and every provision contained on this form. (Signature)
For use by insurer:
I certify and affirm that neither I nor those I am acting for have offered anything of value in
exchange for the claimant’s abandonment of this claim.
Signature of Claims Representative Print Name Date
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Voluntary Abandonment of Claim Date of Injury: Carrier (Colorado DORA)

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Completed 27 January 2021

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