Colorado Workers Compensation Supplemental Report of Return To Work Workers Compensation (WC) # Date of Injury Employee Name Carrier Claim # Social Security # Employer Purpose: The purpose of this form is to provide information to determine the accurate payment of temporary disability benefits. Instructions: 1. This form may be completed by the employee or employer. 2. This form should be completed each time the eployee returns to wm ork at full or reduced wages. 3. This form should be forwarded to your workers compensation carrier. 1. Last day employee worked 2. Date employee returned to work 3. Employees return-to-work-wages (Check the box that applies)
Full Wages
Reduced Wages (Provide wage information to the claims adjuster every 2 weeks during periods of wage loss) Additional Information Completed by (Check the box that applies)
Employee
Employer Name Date Address Phone # ( ) Fax # ( ) WC12 Rev 07/03