FINAL ADMISSION OF LIABILITY 1. Within 30 days, complete the attached objection form or write a letter to the Division of Workers222 Compensation, 633 17 th St., Suite 400, Denver, CO 80202-3660 with a copy to the insurance carrier or self-insured employer stating that you object to this admission. You must also file an application for hearing with the Office of Administrative Courts on any disputed issues. 2. Within the same 30 days, if you disagree with the date of MMI or whole person impairment rating, complete the attached I. Notice and Proposal and II. Application for a Division Independent Medical Examination (DIME) and send it to the insurance carrier or self-insured employer and the Division. 3. If a D IME is requested, you are not required to file an application for hearing until after t he D IME is completed. See page 2 for codes, definitions and other important notices. NOTICE TO CLAIMANT: This Final Admission of Liability is a legal documentnefits that have been or will be paid. You have the right to disagree or object to benefits admitted or not admitted. If you do not object to this admission within 30 calendar days of the date of the final admission, your file will automatically close. Objection information is attached. If you disagree with the benefits admitted or not admitted you must do the following: American LegalNet, Inc. www.FormsWorkFlow.com NOTICE TO CLAIMANT: YOU ARE HEREBY 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. BENEFITS: Medical Benefits Maximum Medical Improvement (MMI) Facial or Bodily Disfigurement Temporary Total Disability (TTD) Temporary Partial Disability (TPD) Permanent Partial Disability (PPD) Whole Person Impairment Scheduled Impairment Part of body codes for scheduled ratings: If you have any questions or need forms, contact the Division of Workers222 Compensation, Customer Service Unit at 303.318.8700 or toll - free at 888.390.7936 or visit our website at www.colorado.gov/cdle/dwc. American LegalNet, Inc. www.FormsWorkFlow.com OBJECTION TO FINAL ADMISSION OF LIABILITY If you disagree with the Final Admission, WITHIN 30 CALENDAR DAYS of the date of the Final Admission you must complete the below Objection Final Admission with Certificate of or write a letter to the Division of Workers222 Compensation, 633 17th St., Suite 400, Denver, CO 80202-3626, with a copy to the insurance carrier or self-insured employer, stating your objection. Within the same 30 days, if you disagree with the date of Maximum Medical Improvement (MMI) and/or Whole Person Permanent Impairment*, you must complete the attached I.Notice and Proposal form and II. Application for Division Independent Medical Examination (DIME) and send itto the insurance carrier or self-insured employer. If a DIME has already determined MMI and/or Whole PersonImpairment, you must request a hearing on any disputed issues. Otherwise, your claim will be closed as to issuesadmitted in the Final Admission of Liability. Objection to Final Admission I contest this admission. I understand that I will be responsible for the cost of the DIME; if youare unable to afford this cost, please request additional information regarding the Application for IndigentDetermination. If a DIME is requested, I am not required to file an Application for Hearing on any disputedissues that are ready for hearing until after completion of the DIME.*Note: If you believe that a scheduled rating should be a whole person rating, you may request a DIME. If youdisagree with a scheduled rating or believe that the scheduled rating should be converted to a whole personrating, you may proceed directly to hearing without a DIME. Certificate of Mailing American LegalNet, Inc. www.FormsWorkFlow.com COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT Notice and Proposal and Application for a Division Independent Medical Examination (DIME)I.Notice and Proposal þ Claimant þ þ Carrier Date of Injury: þ Need for Interpreter? þ þ Yes þ þ No Phone #: þ þ þ State: þ þ Zip: þ Phone #: þ Phone #: þ Phone #: þ Requesting party:WC#:Claimant222s Name:Email:Claimant222s Address:City:*Claimant222s Attorney:Email:Carrier:Adjuster Name:Email:*Carrier222s Attorney:Email: Phone #: *If the claimant and/or insurer is/are represented by an attorney, all Division correspondence will be issued only to theattorney(s) listed. American LegalNet, Inc. www.FormsWorkFlow.com COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT II.Application for a Division Independent Medical Examination (DIME) 1. WC#: Date of Injury: þ Claimant Name: en-USMedical Reason for DIME 2. en-USa) The Physician will consider the issues ofen-US en-USMaximum Medical Improvement, Permanent Impairment,en-USand Apportionment.en-USen-USbe deemed incomplete unless all of the checked areas are addressed. en-USen-USen-USLeften-USHand en-USWrist en-USElbow en-USShoulder en-USCarpal Tunnel en-USCRPS en-USThoracic Outlet Syndrome (TOS) en-US þ Cervical þ Thoracic þ Lumbar þ Pelvis Sacroiliac Joint en-USen-USen-USLeften-USFoot en-USAnkle en-USKnee en-USHip en-USCRPS en-US þ Psychological Traumatic Brain Injury (TBI) en-US Ear (Hearing) þ Face Temporomandibular Joint (TMJ) Vestibular Disorder Nose and Throat en-US þ Digestive þ Skin þ Hernia Urinary & Reproductive þ Cardiovascular þ Respiratory/Pulmonary þ Hematopoietic þ Visual þ Endocrine en-US American LegalNet, Inc. www.FormsWorkFlow.com 3. en-USen-US (The location in which the claimant resides may takeen-USprecedence over the preferred location): en-US 4. en-USMedical Provider Historyen-USList the name AND address of each physician who has evaluated or treated the claimant for this and/oren-USany other medical condition or injury. If a physician assigned an MMI date or an impairment rating, listen-USthe information. At least one MMI date must be listed for the DIME to proceed. Attach additional pages,en-US en-USPhysician Nameen-USPhysician Addressen-US en-US(Street Address, City, State and Zip)en-USMMI Dateen-US% Ratingen-US(WP or Extremity) American LegalNet, Inc. www.FormsWorkFlow.com 5. en-USen-USen-US box only. en-USIf less than two (2) yearsen-US after the date of injury and/or less than three (3) body regions. en-USIf two (2) or more yearsen-USen-USbody regions. en-USen-USen-USThe requesting party will be responsible for payment of the DIME to the selected physician unless an order en-USof indigence has been granted. en-USIf parties agree on a DIME physician during the negotiation process the parties shall agree upon a fee with en-USthe physician. en-US6. en-USDivision of Workers222 CompensationDIME Unit633 17th St., Suite 400Denver, CO 80202-3626DIME Unit Email: imeunit@state.co.usDime Unit Fax: 303-318-8659Claimant: Claimant222s Attorney: : 222 Attorney: By: en-US Signature of Requesting Party en-USIf you have any questions about the DIME process, please contact the Division of Workers222 Compensation en-USCustomer Service at 303-318-8700. en-USResource:en-US American LegalNet, Inc. www.FormsWorkFlow.com