DEPARTMENT OF LABOR AND EMPLOYMENT Division of Workers' Compensation 633 17th Street, 4th Floor Denver, CO 80202-3626 (303) 318-8700 REQUEST FOR SERVICES Date: ________________________________ Claimant Name: SSN: ________________________________________ _________________________________________________________________________________ W.C. # Copy Complete File Certified Copy DOWC Use Only LOC PGS Service Requested: Examine Records Copy Paper Clipped Pages Only Other: Authority to this information: Enclosed Entry Enclosed Release A Party to W.C. #: a. Employer ______________________________________ b. Insurance Carrier c. Claimant _______________________________________________ Attorney for Claimant or Respondent Name of Requesting Attorney: ______________________________________ Note: Dates of injury after July 1, 1989 require a Division notarized authorization signed by the claimant, for all non-party requestors. Billing Information Job #: ____________________________________ Contact: ____________________________________ Agency: ____________________________________ Address: ____________________________________ ____________________________________ ____________________________________ Invoice #: Phone #: ( Fax #: ( JOB: Received By: Date: ) Mail ______________________ ) ________________ _________________ Pickup Rush _________________________________ DOWC Use Only Ext. _______ __________________________________ DOWC Use Only Quantity Copy Rush Certified Copy Fax Item Unit Cost $0.25 $0.50 $2.00 $1.00 Total Cost Approved Copied Contacted Posted By Date Postage TOTAL SUBMIT COMPLETED FORM TO: cdle_dowc_rfs@state.co.us WC 134 Rev. 06/16 DO NOT PRINT/MAIL American LegalNet, Inc. www.FormsWorkFlow.com