FATAL CASE - GENERAL ADMISSION Workers’ Compensation (WC) # ___________________________ Deceased’s Name ______________________________________ Deceased’s Social Security # _____________________________ Date of Injury_________________________________________ Insurance Carrier ______________________________________ Third Party Administrator ________________________________ Carrier Claim # ___________________________________________ Average Weekly Wage _____________________________________ Date of Death _____________________________________________ Weekly Compensation Rate __________________________________ Employer ________________________________________________ NOTICE TO CLAIMANT This is an important legal document that can affect your rights. If you disagree with the amount or type of benefits which the carrier has agreed to pay, you may write a letter to the Division of Workers’ Compensation, 633 17th Street, Suite 400, Denver, CO 80202-3660, stating that you object to this admission. Please send a copy to the insurance carrier or self-insured employer. See page 2 for other important notices. Liability is admitted for the following benefits: Medical Benefits Safety Rule Violation Funeral Expenses $ ___________________ Offset (Attach Calculation) Complete the following for each known dependent: (Attach additional pages, if needed) Name Birth Date Attending School Yes or No If no dependents, has payment been made to the Subsequent Injury Fund (SIF)? Relationship Yes Whole or Partial Dependency(W or P) No Remarks: (Attach additional pages, if needed) BENEFIT HISTORY - Dependents= benefits (past and present) are admitted for the following: Name Time Periods __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ The above time periods include the dates specified. (Attach additional pages, if needed) Weeks Rate per Week Totals __________through _________ = ______ x $ ____________ = $______________ __________through _________ = ______ x $ ____________ = $______________ __________through _________ = ______ x $ ____________ = $______________ __________through _________ = ______ x $ ____________ = $______________ __________through _________ = ______ x $ ____________ = $______________ __________through _________ = ______ x $ ____________ = $______________ Amount of Interest Paid $ ___________________________ Amount of Penalties Paid $ __________________________ 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 ______________________________, __________. List names and addresses of all persons copied: Name Address Dependent(s): Dependents’ Attorney(s): Employer: Carrier’s Attorney: Other: Division of Workers’ Compensation, 633 17th Street, Denver, CO 80202-3660 By: __________________________________________________________________ Block # WC151 Rev 05/05 Adj. Code Page 1 of 2 American LegalNet, Inc. www.FormsWorkflow.com (The top portion of this side may be used for mailing address) FATAL CASE - GENERAL ADMISSION IMPORTANT: SEE NOTICE TO CLAIMANT SECTION ON THE OTHER SIDE OF THIS FORM OTHER NOTICES TO CLAIMANT: YOU ARE HEREBY NOTIFIED that the insurance carrier or self-insured employer admits that the fatality reported herein is compensable. YOU ARE ALSO NOTIFIED that if a child support obligation is owed, compensation benefits may be attached and payment of the child support obligation may be withheld and forwarded to the obligee pursuant to C.R.S. section 8-42-124 and C.R.S. section 26-13-122(4). YOU ARE FURTHER NOTIFIED that you must provide written notice of any award for social security, pension, disability or other source of income that might reduce your compensation benefits. This notice must be sent to the insurance carrier or self-insured employer within 20 days after learning of the payment or award. Failure to report may result in suspension of your benefits pursuant to C.R.S. section 8-42-113.5. WC151 Rev 05/05 Page 2 of 2 American LegalNet, Inc. www.FormsWorkflow.com