Form WC95 "Request for Insurer Information" - Colorado

What Is Form WC95?

This is a legal form that was released by the Colorado Department of Labor and Employment - a government authority operating within Colorado. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 2018;
  • The latest edition provided by the Colorado Department of Labor and Employment;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form WC95 by clicking the link below or browse more documents and templates provided by the Colorado Department of Labor and Employment.

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Download Form WC95 "Request for Insurer Information" - Colorado

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REQUEST FOR INSURER INFORMATION
Colorado Division of Workers’ Compensation Coverage Enforcement
You must complete and return this form within 20 days of ___________.
Failure to complete this form in a timely manner will delay the claim process and may result in penalties. Please
type or print the contact information and sign the form. See Page 3 for instructions.
A Block Number will be assigned to the insurer by the Division of Workers’ Compensation once we have
received the completed form. This number identifies the carrier in our system and must be used on required
forms, including First Report transmittals and correspondence submitted to the Division.
.
If you already have a block number with the Division, please list it here:
1. Insurer - Home Office
Name of Carrier
NCCI Provider Group ID#
Carrier FEIN #
NCCI Provider ID#
Street Address/P.O. Box
Phone #
City, State, Zip
Fax #
2. Office Servicing Colorado for Carrier (NOT Third Party Administrator - TPA)
Name of Carrier
Phone #
Street Address/P.O. Box
Fax #
City, State, Zip
3. Colorado Claims Contact (NOT Third-Party Administrator-TPA)
Name of Claims Contact
Email Address
Street Address/P.O. Box
Phone #
City, State, Zip
Fax #
4. Proof of Coverage Contact
Name of Proof of Coverage Contact
Email Address
Street Address/P.O. Box
Phone #
City, State, Zip
Fax #
5. Premium Surcharge Contact
Name of Premium Surcharge Contact
Email Address
Street Address/P.O. Box
Phone #
City, State, Zip
Fax #
WC95 Rev 1/18
REQUEST FOR INSURER INFORMATION
Colorado Division of Workers’ Compensation Coverage Enforcement
You must complete and return this form within 20 days of ___________.
Failure to complete this form in a timely manner will delay the claim process and may result in penalties. Please
type or print the contact information and sign the form. See Page 3 for instructions.
A Block Number will be assigned to the insurer by the Division of Workers’ Compensation once we have
received the completed form. This number identifies the carrier in our system and must be used on required
forms, including First Report transmittals and correspondence submitted to the Division.
.
If you already have a block number with the Division, please list it here:
1. Insurer - Home Office
Name of Carrier
NCCI Provider Group ID#
Carrier FEIN #
NCCI Provider ID#
Street Address/P.O. Box
Phone #
City, State, Zip
Fax #
2. Office Servicing Colorado for Carrier (NOT Third Party Administrator - TPA)
Name of Carrier
Phone #
Street Address/P.O. Box
Fax #
City, State, Zip
3. Colorado Claims Contact (NOT Third-Party Administrator-TPA)
Name of Claims Contact
Email Address
Street Address/P.O. Box
Phone #
City, State, Zip
Fax #
4. Proof of Coverage Contact
Name of Proof of Coverage Contact
Email Address
Street Address/P.O. Box
Phone #
City, State, Zip
Fax #
5. Premium Surcharge Contact
Name of Premium Surcharge Contact
Email Address
Street Address/P.O. Box
Phone #
City, State, Zip
Fax #
WC95 Rev 1/18
6. EDI Business Contact
Name of EDI Business Contact
Email Address
Street Address/P.O. Box
Phone #
City, State, Zip
Fax #
7. EDI Technical Contact
Name of EDI Technical Contact
Email Address
Street Address/P.O. Box
Phone #
City, State, Zip
Fax #
8. Office Adjusting Colorado Workers’ Compensation Claims
(Third Party Administrator–TPA)
If there is more than one adjusting company, attach additional pages with full information for each.
Name of Adjusting Company
Email Address
Street Address/P.O. Box
Phone #
City, State, Zip
Fax #
9. Person Completing Form (Please Type or Print)
Name
Email Address
Title
Phone #
Signature (REQUIRED)
Date
Return this form to:
Division of Workers’ Compensation
Coverage Enforcement Unit
633 17th Street, Suite 400
Denver, CO 80202
WC95 Rev 1/18
INSTRUCTIONS
1. Complete the name, address, phone and fax numbers of the Home Office of the insurer. Enter the Federal
Employer Identification Number (FEIN), NAIC code and NCCI Carrier Code numbers for the home office of the
insurance carrier.
2. Complete the name, address, phone and fax numbers of the office that services Colorado. This is the address that the
Division uses to send correspondence such as rules and administrative notices. If this section is blank, correspondence
will be sent to the Home Office listed in section #1 above. If a Third-Party Administrator (TPA) services Colorado for
the carrier, do not list the TPA in this section. List the TPA in Section #10.
3. Complete the name, address, phone and fax numbers, and email address for the person designated as the Claims
Contact for Colorado claims. This person must be able to assist injured workers, deal with non-compliance
issues, prepare for compliance reviews and have the authority to respond to audits by the Division of Workers’
Compensation. This address will receive workers’ claims for compensation, correspondence regarding admissions,
notice of contest information, and similar correspondence. If a Third-Party Administrator (TPA) services Colorado for
the carrier, do not list the TPA in this section. List the TPA in Section #10.
4. Complete the name, address, phone and fax numbers, and email address for the person designated as the Proof of
Coverage Contact for Colorado policies. This person must be able to assist with policyholder FEIN questions and
general policy inquiries from the Division. Reports, including Show Cause Orders, relating to the carrier’s reporting
of policy information are sent to this person.
5. Complete the name, address, phone and fax numbers, and email address for the person designated as the Premium
Surcharge Contact. This person will receive premium surcharge notification letters and is responsible for completing
the surcharge report and submitting payment to the Division.
6. Complete the name, address, phone and fax numbers, and email address for the person designated as the Electronic
Data Interchange (EDI) Business Contact. This should be the person most familiar with the overall extract and
transmission process within your business entity. This may be the project manager, business analyst, or claims
manager. This person should be able to track down the answers to any business EDI issues that the EDI Technical
Contact cannot address.
7. Complete the name, address, phone and fax numbers, and email address for the person designated as the Electronic
Data Interchange (EDI) Technical Contact. This person will be contacted if issues regarding the actual transmission
process arise. This person may be a telecommunications specialist, computer programmer or systems analyst.
8. If the insurer uses a Third-Party Administrator (TPA) to adjust Colorado claims, complete the name, address, phone
and fax numbers of the TPA office. If there is more than one TPA office, or more than one location for the TPA, attach
a separate page listing the required information for all additional TPA offices and/or locations.
9. Print the name, title, phone number, and email address of the person completing this form. This person must sign
the form.
Return the completed form to:
Division of Workers’ Compensation
Coverage Enforcement Unit
633 17th Street, Suite 400
Denver, CO 80202
Any changes to this information must be reported to the Division of Workers’ Compensation in writing.
If you have any questions, please contact the Division of Workers’ Compensation at 303.318.8700
.
WC95 Rev 1/18
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