Form WC134 "Request for Services" - Colorado

What Is Form WC134?

This is a legal form that was released by the Colorado Department of Labor and Employment - a government authority operating within Colorado. Check the official instructions before completing and submitting the form.

Form Details:

  • Released on June 1, 2016;
  • 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 WC134 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 WC134 "Request for Services" - Colorado

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DEPARTMENT OF LABOR AND EMPLOYMENT
Division of Workers’ Compensation
th
th
633 17
Street, 4
Floor
Denver, CO 80202-3626
(303) 318-8700
REQUEST FOR SERVICES
Date: ________________________________
SSN:
________________________________________
Claimant Name:
_________________________________________________________________________________
Service Requested:
DOWC Use Only
W.C. #
Examine Records
Copy Complete File
LOC
PGS
Copy Paper Clipped Pages Only
Certified Copy
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 #: ____________________________________
Invoice #:
______________________
DOWC Use Only
Contact: ____________________________________
Phone #: (
)
________________
Ext. _______
Agency: ____________________________________
Fax #: (
)
_________________
Address: ____________________________________
JOB:
Mail
Pickup
Rush
____________________________________
Received By:
_________________________________
____________________________________
Date:
__________________________________
DOWC Use Only
Quantity
Item
Unit Cost
Total Cost
By
Date
Copy
$0.25
Approved
Rush
$0.50
Copied
Certified Copy
$2.00
Contacted
Fax
$1.00
Posted
Postage
TOTAL
DO NOT PRINT/MAIL
SUBMIT COMPLETED FORM TO: cdle_dowc_rfs@state.co.us
WC 134 Rev. 06/16
Clear This Form
DEPARTMENT OF LABOR AND EMPLOYMENT
Division of Workers’ Compensation
th
th
633 17
Street, 4
Floor
Denver, CO 80202-3626
(303) 318-8700
REQUEST FOR SERVICES
Date: ________________________________
SSN:
________________________________________
Claimant Name:
_________________________________________________________________________________
Service Requested:
DOWC Use Only
W.C. #
Examine Records
Copy Complete File
LOC
PGS
Copy Paper Clipped Pages Only
Certified Copy
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 #: ____________________________________
Invoice #:
______________________
DOWC Use Only
Contact: ____________________________________
Phone #: (
)
________________
Ext. _______
Agency: ____________________________________
Fax #: (
)
_________________
Address: ____________________________________
JOB:
Mail
Pickup
Rush
____________________________________
Received By:
_________________________________
____________________________________
Date:
__________________________________
DOWC Use Only
Quantity
Item
Unit Cost
Total Cost
By
Date
Copy
$0.25
Approved
Rush
$0.50
Copied
Certified Copy
$2.00
Contacted
Fax
$1.00
Posted
Postage
TOTAL
DO NOT PRINT/MAIL
SUBMIT COMPLETED FORM TO: cdle_dowc_rfs@state.co.us
WC 134 Rev. 06/16