Fillable WORKERS CLAIM FOR COMPENSATION TRANSMITTAL (Colorado DORA)

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WORKERS CLAIM FOR COMPENSATION TRANSMITTAL (Colorado DORA)

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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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WC 174 Rev. 01/17
COLORADO DIVISION OF WORKERS’ COMPENSATION
WORKER’S CLAIM FOR COMPENSATION TRANSMITTAL
Submitted By:
Attorney:
Mailing Address
Phone #
( )
Fax #
( )
An Entry of Appearance MUST accompany this form.
NAME
SS#
WC#
Division Assigned
INSTRUCTIONS
The Worker’s Claim for Compensation Transmittal Form (Transmittal) is used by attorneys at law to submit Worker’s
Claims for Compensation. The Transmittal Form MUST be accompanied by an Entry of Appearance form. The
Transmittal will be returned via fax noting the Workers’ Compensation number (WC#) assigned by the Division. This
WC# must be listed on all future documents relating to the claim.
The Transmittal MUST be placed on top of the Entry of Appearance.
Attorney: List the name of the attorney submitting the form.
Mailing Address: List the mailing address of the attorney submitting the form.
Phone #: List the telephone number of the attorney submitting the form.
Fax #: List the Fax number of the attorney submitting the form.
Name: List the name of the claimant.
SS #: List the Social Security Number of the claimant.
DOI: List the date of injury.
WC#, Division Assigned: Do not complete. The Division will assign the Workers’ Compensation number.
Mail or Deliver to:
Division of Workers' Compensation
633 17
th
St., Suite 400
Denver, CO 80202-3626
303.318.8700
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WORKERS CLAIM FOR COMPENSATION TRANSMITTAL (Colorado DORA)

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Completed 27 January 2021

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