Form WC174 "Worker's Claim for Compensation Transmittal" - Colorado

What Is Form WC174?

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, 2017;
  • 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 WC174 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 WC174 "Worker's Claim for Compensation Transmittal" - Colorado

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COLORADO DIVISION OF WORKERS’ COMPENSATION
WORKER’S CLAIM FOR COMPENSATION TRANSMITTAL
Submitted By:
Attorney:
Phone # (
)
Mailing Address
Fax # (
)
An Entry of Appearance MUST accompany this form.
NAME
SS#
DOI
WC#
Division Assigned
INSTRUCTIONS
The Worker’s Claim for Compensation Transmittal Form (Transmittal) is used by attorneys at law to submit Worker’s
Claims for Compensation. The Transmittal Form MUST 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 future documents relating to the claim.
The Transmittal MUST be placed on top of the Entry of Appearance.
Attorney: List the name of the attorney submitting the form.
Mailing Address: List the mailing address of the attorney submitting the form.
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.
SS #: List the Social Security Number of the claimant.
DOI: List the date of injury.
WC#, Division Assigned: Do not complete. The Division will assign the Workers’ Compensation number.
Mail or Deliver to:
Division of Workers' Compensation
th
633 17
St., Suite 400
Denver, CO 80202-3626
303.318.8700
WC 174 Rev. 01/17
COLORADO DIVISION OF WORKERS’ COMPENSATION
WORKER’S CLAIM FOR COMPENSATION TRANSMITTAL
Submitted By:
Attorney:
Phone # (
)
Mailing Address
Fax # (
)
An Entry of Appearance MUST accompany this form.
NAME
SS#
DOI
WC#
Division Assigned
INSTRUCTIONS
The Worker’s Claim for Compensation Transmittal Form (Transmittal) is used by attorneys at law to submit Worker’s
Claims for Compensation. The Transmittal Form MUST 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 future documents relating to the claim.
The Transmittal MUST be placed on top of the Entry of Appearance.
Attorney: List the name of the attorney submitting the form.
Mailing Address: List the mailing address of the attorney submitting the form.
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.
SS #: List the Social Security Number of the claimant.
DOI: List the date of injury.
WC#, Division Assigned: Do not complete. The Division will assign the Workers’ Compensation number.
Mail or Deliver to:
Division of Workers' Compensation
th
633 17
St., Suite 400
Denver, CO 80202-3626
303.318.8700
WC 174 Rev. 01/17