DEPARTMENT OF LABOR AND EMPLOYMENT Division of Workers' Compensation Research and Statistics Unit 633 17th Street, Suite 400 Denver, CO 80202-3626 MONTHLY SUMMARY Date Completed ___________________________ Carrier Number ______________________________ Carrier Name __________________________________________________________________________ Summary of injuries reported pursuant to Section 8 -43-101(2) C.R.S. as amended. Total number of medical-only cases accepted for payment (no lost time in excess of 3 days, etc.) including occupational disease not listed Rule 5-2(B). 1 Total number of exposures to injurious substances Totals January February March April May June July August September October November December 1 List of exposures to injurious substances: ___________________________________________________________ _______________________________________________________________________________________________ Remarks: _______________________________________________________________________________________ ______________________________________________________________________________________ Contact: Address: WC098 Rev 01/06 American LegalNet, Inc. www.FormsWorkFlow.com