Request For A Disfigurement Award Form. This is a Colorado form and can be use in Workers Comp.
Tags: Request For A Disfigurement Award, Colorado Workers Comp,
Workers' Compensation Disfigurement Benefits Colorado law provides for a claimant to be paid benefits if a claimant has a scar or other disfigurement due to an industrial injury or occupational disease. Section 8-42-108, C.R.S. For an injury that occurred before July 1, 2007, a claimant is entitled to an award for disfigurement of up to $2,000 if he or she has a serious and permanent scar or other disfigurement to the head, face or parts of the body normally exposed to public view. For an injury that occurred on or after July 1, 2007, a claimant is entitled to an award for disfigurement of up to $4,000 if he or she has a serious and permanent scar or other disfigurement to the head, face or parts of the body normally exposed to the public view. "Permanent" usually means that the scar or disfigurement exists at least six months after the date of the injury or last surgery, or that a physician has determined that the claimant has reached maximum medical improvement. "Public view" means that the scar or disfigurement is visible when the claimant is wearing a swimsuit. Recent changes to Colorado law now entitle a claimant to an award of up to $8,000 if he or she has extensive facial scars or facial burns scars; extensive body scars or burn scars; or stumps due to loss or partial loss of limbs. Section 8-42-108(2), C.R.S. If the claimant believes that an award for disfigurement is appropriate in his or her claim, and no further surgery is anticipated, the claimant should contact the insurer (or employer if there is no insurer) and request payment of disfigurement benefits. If the claimant and insurer are unable to agree on the amount of the disfigurement benefit, the claimant may request that an Administrative Law Judge determine the amount of the disfigurement benefit. A party may have an Administrative Law Judge determine the amount of additional compensation due a claimant for disfigurement as follows: A. By Photograph: A party may submit a Request for a Disfigurement award to the Office of Administrative Courts ("OAC"). A photograph or photographs clearly showing the disfigurement and the face of the claimant shall accompany the request. The claimant shall sign the back of the photographs and state the date the photograph was taken. The date the photograph was taken must be at least six months after the date of the injury or surgery, or after the date of maximum medical improvement. The signature of the claimant is the claimant's certification that the photograph accurately depicts the disfigurement on the date the photograph was taken. A copy of the request, and a copy of the photographs, shall be provided to all opposing parties. Any party may request reconsideration of a disfigurement award by photograph by filing, within twenty days of the date of the certificate of mailing of the disfigurement award, an Application for Hearings listing disfigurement as an issue. If such an application is filed, the disfigurement award will be withdrawn and vacated. B. At a Hearing: A party may file an Application for Hearing with the Office of Administrative Courts listing disfigurement as an issue. If disfigurement is the only issue listed, the hearing shall be set 30 to 60 days after the date of the setting. If you have any questions, please call the OAC at 303-866-2000. American LegalNet, Inc. www.FormsWorkFlow.com STATE OF COLORADO OFFICE OF ADMINISTRATIVE COURTS 633 17th Street, Suite 1300 Denver, Colorado 80202 In the Matter of the Workers' Compensation Claim of: Claimant, vs. Employer, and COURT USE ONLY CASE NUMBER: CLAIMANT SSN: Insurer, Respondents. REQUEST FOR A DISFIGUREMENT AWARD (PHOTO) I was injured as the result of an industrial injury or occupational disease that occurred I have a serious permanent on ______________________________ (date). disfigurement to an area of my body normally exposed to public view. The disfigurement is to my ________________________________________________________________ (part or parts of body disfigured that are normally exposed to public view). The injury occurred at least six months ago, or my authorized treating physician has placed me at maximum medical improvement. I have attached photographs that clearly show the disfigurement, and have dated and signed the back of each photograph. Dated: (Signature of Claimant) Address and Phone Number: Revised 10/19/05 American LegalNet, Inc. www.FormsWorkFlow.com (A copy of this completed form and a copy of the photographs must be delivered or mailed to the Respondent-Insurer. The original form with the photographs and any other attachments should be delivered or mailed to the nearest office of the Office of Administrative Courts.) CERTIFICATE OF MAILING OR DELIVERY A copy of this Request for a Disfigurement Award was mailed or delivered on ____________________ (date) to the Office of Administrative Courts at (mark one): Office of Administrative Courts th 633 17 Street, Suite 1300 Denver, CO 80202 Office of Administrative Courts th 222 South 6 St., Ste 414 Grand Junction, CO 81501 Office of Administrative Courts 1259 Lake Plaza Drive, Suite 230 Colo. Springs, CO 80906 And to the Respondent-Insurer at: (Signature) Revised 1/13/09 American LegalNet, Inc. www.FormsWorkFlow.com