Page 1 of 2 COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT Division of Workers222 CompensationFATAL CASE - FINAL ADMISSION WC #: � Deceased222s SS#: � Deceased222s Name: � Date of Injury: � Insurance Carrier: � Carrier Claim #: � Average Weekly Wage: � Date of Death: � Weekly Comp. Rate: � Employer: � NOTICE TO DEPENDANT: � � � � Me �� Safety Rule Violation � � Funeral Expenses $ � � � Offset (Attach Calculation)Complete the following for each known dependent: (Attach additional pages, if needed) NameBirth DateAttending School?Yes or NoRelationshipWhole or Partial Dependency (W or P) If no dependents, has payment been made to the Colorado Uninsured Employer Fund? � � Yes � � No If no dependents, has payment been made to the Subsequent Injury Fund (SIF)? � � Yes � � NoRemarks: (attach additional pages, if needed) American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 2 � Name � Time Periods � Weeks � Rate per Week � Totals � � � through � = � x $ � � = $ � � � � through � = � x $ � � = $ � � � � through � = � x $ � � = $ � � � � through � = � x $ � � = $ � � � � through � = � x $ � � = $ � � � � � Amount of Penalties Paid � $ � (Attach additional pages, if needed) � Amount Overpaid � $ � (See Remarks) Claims Representative � � Phone # � � � Toll-Free Phone # � � Address: � CERTIFICATE OF MAILING: � Copies of this document were placed in the U.S. mail or delivered to the following parties this � � � day of � � , � � .Dependent(s):Dependents222 Attorney(s):Employer:Carrier222s Attorney:Other:Division of Workers222 Compensation, 633 17th Street, Suite 400, Denver, CO 80202-3626By: � � FATAL CASE - FINAL ADMISSION American LegalNet, Inc. www.FormsWorkFlow.com