Colorado workers compensation form 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the W.C. Number at the top of the form, followed by the insurance carrier's name and the claimant's name.
3. Fill in the Social Security Number and Date of Accident/Injury fields accurately.
4. Provide the claimant’s mailing address, ensuring all details are correct, including street address, state, and zip code.
5. In Section I, list all medical expenses incurred by the insurance carrier or self-insured employer. Include amounts for treating physician expenses, hospital costs, and any other relevant categories.
6. If applicable, indicate whether you are aware of any third-party activity on this claim by checking 'Yes' or 'No'.
7. Sign and date the form as both the claimant and insurance carrier representative where indicated.
8. Finally, review all entries for accuracy before submitting your completed form to the Division of Workers’ Compensation.

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