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Workers Claim For Compensation Transmittal Form. This is a Colorado form and can be use in Workers Comp.
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Tags: Workers Claim For Compensation Transmittal, WC174, Colorado Workers Comp,
COLORADO DIVISION OF WORKERS’ COMPENSATION
WORKER’S CLAIM FOR COMPENSATION
COURT
COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
......... ..
:
Index No.
:
Submitted By:
Plaintiff(s)
Attorney:
TRANSMITTAL
-against-
Calendar No.
:
JUDICIAL SUBPOENA
:
Mailing Address
:
:
Phone #
(
)
Fax #
(
)
Defendant(s)
:
......................................................
An Entry of Appearance should accompany this form.
THE PEOPLE OF THE STATE OF NEW YORK
NAME
TO
SS#
DOI
WC#
Division Assigned
GREETINGS:
WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before
,
the Honorable
at the
Court
INSTRUCTIONS
located at
County of
in room
, on the
day of
, 20
, at
o'clock in the
noon, and at any recessed
or for Compensation Transmittal Form (Transmittal) this action attorneys at law
The Worker’s Claimadjourned date, to testify and give evidence as a witness inis used byon the part of the to submit Worker’s
Claims for Compensation. The Transmittal Form should be accompanied by an Entry of Appearance form. The
Transmittal will be returned via fax noting the Workers’ Compensation number (WC#) assigned by the Division. This
WC# must be listed on all futurefailure to comply with to the claim. is punishable as a contempt of court and will make you liable to
Your documents relating this subpoena
the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a
The Transmittal MUST be your failure topcomply. Entry of Appearance.
result of placed on to of the
Attorney: List the name of the attorney submitting the form.
Witness, Honorable
County,
day of
, the
Mailing Address: Court the mailing address of the attorney submitting20 form.
List in
, one of the Justices of the
Phone #: List the telephone number of the attorney submitting the form.
Fax #: List the Fax number of the attorney submitting the form.
Name: List the name of the claimant.
(Attorney must sign above and type name below)
Attorney(s) for
SS #: List the Social Security Number of the claimant.
DOI: List the date of injury.
Office and P.O. Address
WC#, Division Assigned: Do not complete. The Division will assign the Workers’ Compensation number.
Mail or Deliver to:
Telephone No.:
Facsimile No.:
Division of Workers' Compensation
633 17th St., Suite 400 E-Mail Address:
Denver, CO 80202-3660 Mobile Tel. No.:
303.318.8700
WC 174 Rev. 05/05
I
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