COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT DIVISION OF WORKERS’ COMPENSATION FINAL PAYMENT NOTICE Reason for Filing - Whenever a worker’s compensation claim has been closed, the Insurer shall file a Final Payment Notice within 60 days of the date of closure. The information on this form captures the Insurer/TPA claim number, cost of claims for statistical reporting of trends, and for reports to the legislature. This Final Payment Notice is being filed for the following reason: (check one) Full and Final Settlement Type of Filing (check one) Final Order Original Closure Order Amended Final Admission Other Date Mailed/Delivered WC # Claimant’s Name SS # Insurer/TPA Claim # Insurer Name TPA Name Date of Injury Date of MMI Adjuster Name Adjuster Phone Total Paid TTD # of Weeks Paid # of Days Paid TPD Employer Paid (§ 8-42-124, C.R.S.) Whole Person PPD Scheduled PPD % % % Part of Body % Part of Body % Part of Body Part of Body (See Part of Body Table) Part of Body Table Final Admission Body Codes Converting To Final Payment Notice (FPN) Body Codes PTD Disfigurement Colorado Part Of Body Code Hospital Costs 01 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 25 26 27 28 29 30 31 37 33 34 35 Arm @ Shoulder Hand @ Wrist Thumb @ Metacarpal Thumb @ Proximal Thumb @ Distal Index @ Metacarpal Index @ Proximal Index @ Second Index @ Distal Middle @ Metacarpal Middle @ Proximal Middle @ Second Middle @ Distal Ring @ Metacarpal Ring @ Proximal Ring @ Second Ring @ Distal Little @ Metacarpal Little @ Proximal Little @ Second Little @ Distal Leg @ Hip Leg @ Foot, Heel, Ankle Great Toe @ Metatarsal Great Toe @ Proximal Great Toe @ Distal Other Toe @ Metatarsal Other Toe @ Proximal Other Toe @ Distal Loss of Tooth Blindness One Eye Deafness Both Ears Deafness One Ear 31 34 37A 37B 37C 36A 36B 36C 36D 36E 36F 36G 36H 36I 36J 36K 36L 36M 36N 36O 36P 52 56 58A 58B 58C 57C 57D 57G 16 14B 13A 13B Upper Arm Wrist Thumb @ Metacarpal Thumb @ Proximal Joint Thumb @ Distal Joint Index @ Metcarpal Index @ Proximal Index @ Second Joint Index @ Distal Joint Middle @ Metacarpal Middle @ Proximal Middle @ Second Joint Middle @ Distal Joint Ring @ Metacarpal Ring @ Proximal Ring @ Second Joint Ring @ Distal Joint Little @ Metacarpal Little @ Proximal Joint Little @ Second Joint Little @ Distal Joint Upper Leg Foot Great Toe @ Metatarsal Great Toe @ Proximal Great Toe @ Distal Joint Other Toe @ Metatarsal Other Toe @ Proximal Other Toe @ Distal Joint Tooth/Teeth Total Blindness One Eye Total Deafness Both Ears Total Deafness One Ear 36 Total Hearing 2nd Ear 13C Total Hearing 2nd Ear Physician Costs Other Medical Costs Settlement/Stipulation Legal Costs Interest Paid Penalties Paid Fatal Benefits Date of Death: Funeral Costs Vocational Rehab Maintenance (RMB) Other Rehabilitation Maintenance (VR Services) Description Colorado Part Of Body Code FPN Body Codes Description Of Final Payment Block # WC 25 Rev. 08/10 Adj. Code Page 1 American LegalNet, Inc. www.FormsWorkFlow.com INSTRUCTIONS/DEFINITIONS Report the full amount paid by benefit type. Report cumulative costs on any subsequent Final Payment Notices filed for the same claim. Reason for Filing Check the appropriate category reflecting the reason for filing. If Other, please specify. Type of Filing Check Original if this is the first Final Payment Notice filed by this party on this claim. A Final Payment Notice is required to be filed 60 days after closure of a claim. Check Amended if the Original Final Payment Notice was filed in error or if additional benefits were paid after the original filing. Report cumulative totals on all amended Final Payment Notices. Date Mailed Date Final Payment Notice was mailed or delivered to the Division. Claim Demographics WC # Claimant’s Name SS # Date of Injury Date of MMI Insurer/TPA Claim # Insurer Name TPA Name Adjuster Name Adjuster Phone Total Paid TTD Number assigned by the Division to identify the specific claim. If the Settlement involves multiple claims, report the settlement amount on only one claim. Report amounts paid on the other claims (where any benefits were paid) on a separate Final Payment Notice for each claim. Injured worker’s legally recognized full name. Number assigned by the Social Security Administration to identify the employee. Date of the accident or date of notice of an occupational disease or exposure. Date of maximum medical improvement (MMI) after which further recovery from or improvement to an injury or disease can no longer be anticipated based on reasonable medical probability. Number assigned by the Insurer or Third Party Administrator to identify the specific claim. Name of the insurer or self-insured employer assuming financial responsibility for the claim. Name of the Third Party Administrator contracted to adjust the claim, if applicable. Name of the person administering the claim. Telephone number of the adjuster. Date of Death Funeral Costs Vocational Rehabilitation Maintenance Other Rehabilitation Maintenance List actual amounts paid prior to this filing. Temporary Total Disability (TTD) benefits paid for the period claimant was unable to earn any wages and not reported as Employer Paid benefits (§ 8-42-124). Number of whole weeks paid for the listed TTD benefits. Number of days paid for the listed TTD benefits, not included in the number of weeks paid. Temporary Partial Disability (TPD) benefits paid for the period during which the claimant was unable to earn full wages and not reported as Employer Paid benefits (§ 8-42-124). Lost-time benefits reimbursed to the employer pursuant to § 8-42-124 and not reported as TTD or TPD benefits in the above categories. Permanent Partial Disability (PPD) benefits paid for permanent medical impairment not listed on the schedule. List only actual amounts paid. Permanent impairment rating for impairment not listed on the schedule. Permanent Partial Disability (PPD) benefits paid per the statutory schedule at § 8-42-107(2). List only actual amounts paid. Permanent impairment rating for impairment to the scheduled part of body. The code corresponding to the part of body for the scheduled injury impairment rating. See Part of Body Table on the front of the form. Use the code in the first column of the Table. Permanent Total Disability (PTD) benefits paid for medical impairment and other factors that render the claimant unable to earn any wages. Benefits paid for permanent scarring. Total paid to hospitals for services for this claim. Total paid to physicians for services for this claim. Total paid for medical services not otherwise reported for this claim. Settled amounts over and above other amounts paid and not reported elsewhere on this form. Report cumulative costs on any subsequent Final Payment Notices filed for the same claim. Total respondents’ legal expenses paid for this claim. Total interest paid for this claim. Total penalties paid for this claim. Compensation benefits paid for death resulting from a work-related accident or occupational disease. On a fatal claim, the date the injured worker died. Total funeral expenses paid for this claim. Total weekly maintenance benefits paid while the claimant participated in a vocational rehabilitation program. Total paid vocational rehabilitation evaluation and education services plus other vocational services not otherwise reported for this claim. Insurer Identifying Information Block # Adj. Code Three-digit Division assigned number identifying the insurer or self-insured employer listed above. Two-alpha character Division assigned code identifying the TPA listed above. # of Weeks Paid # of Days Paid TPD Employer Paid Whole Person PPD Whole Person % Scheduled PPD Scheduled Injury % Part of Body PTD Disfigurement Hospital Costs Physician Costs Other Medical Costs Settlement/Stipulation Legal Costs Interest Paid Penalties Paid Fatal Benefits American LegalNet, Inc. www.FormsWorkFlow.com