Request for Offset of Liability for Workers' Compensation - Colorado 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling in the claimant's name and W.C. number at the top of the form. Ensure accuracy as this information is crucial for processing your request.
3. Next, provide details about the employer, including their name and insurance carrier information. This section helps identify all parties involved.
4. Indicate the date of injury clearly. This date is essential for establishing timelines related to your claim.
5. If claiming an offset under Section 8-46-101, complete Section A by listing prior industrial disabilities, including employer names, W.C. numbers, descriptions of injuries, and awards received.
6. For claims under Section 8-41-304, fill out Section B with details about occupational diseases, specifying types of exposure, approximate dates, and employer information.
7. Finally, sign and date the request at the bottom before submitting it along with any required documents to the Division of Workers’ Compensation.

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