STATE OF COLORADO Division of Workers222 Compensation WCNumber: IN THE MATTER OF THE CLAIM OF Claimant REQUEST FOR DISFIGUREMENT AWARD (PHOTO) v. Employer, and Insurer, Respondents. I was injured as the result of an industrial injury or occupational disease that occurred on , , . month day year I have a serious permanent disfigurement to an area of my body normally exposed to public view. The disfigurement is to my . list part or parts of body that are normally exposed to public view The injury occurred at least six months ago, or my authorized treating physician has placed me at maximum medical improvement. Signed: Dated: Signature of Claimant Print Name: Phone: Address: A copy of this completed form and a copy of the photographs must be delivered or mailed to the Respondent-Insurer. The original form with photographs and any other attachments should be delivered or mailed to the Division of Workers222 Compensation. WC193 Rev. 0 Page 1 American LegalNet, Inc. www.FormsWorkFlow.com CERTIFICATE OF MAILING OR DELIVERY: Copies of this document, Request for Disfigurement Award, were placed in the U.S. mail or delivered to the following parties this day of , . daymonthyear List names and addresses of all parties copied: Employer: Carrier: Carrier222s Attorney: Division of Workers222 Compensation, 633 17t h Street, Suite 400, Denver, CO 80202 By: Signature WC193 Rev. 0 Page 2 American LegalNet, Inc. www.FormsWorkFlow.com