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