DIVISION OF WORKERS’ COMPENSATION SETTLEMENT ROUTING SHEET Customer Service 303.318.8700 Claimant’s name: List all workers’ compensation (WC#) numbers List all attorneys and corresponding registration numbers: included in this settlement: WC#: DOI Claimant’s Attorney Reg. # WC#: DOI Respondent’s Attorney Reg. # WC#: DOI Other Attorney Reg. # WC#: DOI Other Attorney Reg. # Type of settlement (check one): □ Full and Final Settlement (F) □ Partial Settlement (P) □ Third Party (Subrogation) Settlement (T) □ Structured Settlement (S) □ Structured Settlement (L) Total amount of settlement award (Include lump sum plus present value of any structured settlement) $ Double check and verify the following – failure to do so could result in the rejection of your settlement agreement: 1. 2. 3. 4. Workers’ compensation numbers are correct . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Settlement document has original signatures of all parties . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Claimant’s signature is properly notarized . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A standard order is included . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . □ □ □ □ I have reviewed the attached settlement document and order, and believe they comply with the Division rules. Signature Date Print Name □ Claimant □ Respondent □ Representative for: Claimant □ Respondent Resubmitted (if initially rejected) Signature Date Print Name Representative for: Instructions for document return: Will pick up at Customer Service □ Contact person for information: □ Please mail (Division will mail only if sufficient copies, with addressed, stamped envelopes for all parties are attached) Contact person for document pickup: Name Phone number Phone number Name This form must be completed and submitted with the settlement document and order. Include a mailing certificate if the order is to be mailed. Submit the original settlement document and copies for all parties listed on the mailing certificate. Failure to correctly complete and submit all documents may result in rejection or return of the settlement. Settlement documents for claimants not represented by an attorney must be submitted directly to the Prehearing Unit of the Division of Workers’ Compensation, Suite 1300. Do not complete this form if the claimant is unrepresented. Division of Workers’ Compensation Use Only: □ □ Approved Date: By: Rejected (see # ____ above) Date: By: Person picking up documents: Print Name Signature On behalf of: Date: Mail or deliver all documents to: Division of Workers’ Compensation, Customer Service 633 17th St., Suite 400, Denver, CO 80202-3626 WC105 Rev 01/09 American LegalNet, Inc. www.FormsWorkFlow.com