4201 E Arkansas Ave., Room 274, Denver, CO 80222 P 303.757.9491 F 303.757.9409 www.colorado.gov/
A workers’ compensation claim has been reported to our insurance carrier, Broadspire, due to your recent work
related injury/illness.
The Risk Management staff is here to help you with any problems or questions you might have regarding your claim.
Some things you need to be aware of regarding your injury:
• A claim number is not an admission of liability.
• You must be seen by a CDOT Authorized Treating Physician (ATP). Click link for current ATP list.
• You must provide a copy of a completed Work Status Report or supporting documentation to your supervisor after
each appointment for your injury.
• You must track and report all time use for related medical appointments and reasonable travel time and report this
lost time to your supervisor or their designee.
• The first 24 hours are charged to your own leave (Sick, Annual, or LWOP.), and all lost time must be coded to your
own leave until Risk Management issues an approval memo.
• Mileage to and from your medical appts. is reimbursable, send all mileage reimbursement claims to Broadspire.
Click link for Mileage Reimbursement form.
• Provide your Authorized Treating Physicians (ATP) and any other medical providers this number.
• Write the claim number on all claim related documents this will reduce confusion, speed up the decision making
process and protect your rights.
• Please call myMatrixx (855) 326-3732 for pharmacy locations or used the attached form which is accepted by all
major pharmacies.
If you have any questions, need information or requests please call the Risk Management Coordinator above or email
them at: [email protected]
Risk Management Unit
4201 E. Arkansas Ave., Room 274
Denver, CO 80222
DATE: MAY 27, 2015
TO: RON HURT
FROM: CDOT RISK MANAGEMENT TEAM
CC: SUPERVISOR, FML LIAISON, EMPLOYEE RELATIONS
RSO/EEO: ANDY OFFICER
SUBJECT: CLAIM NUMBER INCIDENT TO ACCIDENT
CLAIM NUMBER: XXXXXXXXX
DATE OF ACCIDENT: 5/22/15
CDOT COORDINATOR: (SPECIALIST) RISK MANAGMEMENT
CDOT COORDINATOR: DONNA GOODWIN 303-757-9958
Name Ofrecipient
Company
Another Line
555 Address St. Apt. 55
Denver, CO 80555
