Wc15 - Worker'S Claim For Compensation Page 3
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4COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT
See instructions on reverse side
DIVISION OF WORKERS’ COMPENSATION
before completing form
WORKER’S CLAIM FOR COMPENSATION
Employee’s name (first, middle, last)
Social Security #
Male
Employee’s home phone #
Division Use
Female
Only
Employee’s street address
City
State
Zip code
SOI
Birth date
Marital status
Dependents
Date of hire
Occupation
Employment status
POB
Married
Separated
Yes
Full time
Part time
/
/
/
/
Single
Unknown
No
Other
U
nknown
Employer’s name (Company)
Employer’s phone #
NOI
Employer’s mailing address
City
State
Zip code
Coder
Average Weekly Wage
A.
Calculate the average weekly wage. Multiply the average number of hours
worked per week, excluding overtime, times the hourly wage—see instructions
Subtotal (A) $
B.
Check box if employee receives
Will benefit continue
If benefit will not continue, provide the average weekly
during disability?
value of the benefit
Overtime
Yes
No
$
Tips (amount reported to IRS)
Yes
No
$
Commissions
Yes
No
$
Piecework
Yes
No
$
Mileage (if a form of salary)
Yes
No
$
Other (room, board, etc.)
Yes
No
$
Health Insurance (see instructions)
Yes
No
$
Subtotal (B) $
=
C.
Add subtotals A & B
Average weekly wage at time of injury (C) $
Date of injury/disease
Time employee
Injury time
Last date
Date employer
Date you
Do you claim to have a
began work
____ ____ a.m.
worked
notified
returned to work
permanent disability?
/
/
____ ____
a.m
____ ____ p.m
Yes
No
(See instructions)
/
/
/
/
/
/
Unknown
____ ____
p.m
Unknown
Which part of body was affected? (specify upper or lower for arms, legs and
Tell us the nature of the injury/illness (sprain, strain, laceration,
1
back injuries)
contusion, fracture, etc.)
2
What were you doing just before the accident occurred?
3
How did the injury occur?
4
Name and phone number of witness
What object or substance directly harmed you?
Where did the accident occur? (street address, city, state, and county)
To whom was it reported?
Initial treatment (check one)
Do you claim to have a disfigurement
None
Emergency room
Hospital stay over 24 hrs
or scar?
Minor on-site
Clinic/Hospital
Yes
No
Name and address of treating doctor or other health care professional
Name and address of facility where treated
If claim is for an occupational disease (i.e., asbestos related, repetitive motion, hearing loss), give names of employers where the exposure occurred and
dates of employment (attach additional sheet if needed).
/
/
to
/
/
Employer
Dates of employment
/
/
to
/
/
Employer
Dates of employment
Completed by
Date completed
/
/
For Division Use Only
FEIN
Carrier claim #
Policy #
Adjuster Code
Block #
WC15 Rev 04/06
Page 1 of 2
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