Notice To Workers Compensation Intent To Pursue 3rd Party Claim

 

Attn:

Re:Your Claim Number:

Your Insured:

Date of Loss:

Our Client:

 

Dear . :

Please accept this letter, pursuant to C.R.S. 8-41-203(4), as (client), written notice of intent to pursue a claim. (client) *currently* has a claim for workers’ compensation benefits and, at the time of the injury, (client’s) employer was** .

1. (client) claim arises from an automobile collision that occurred on (date). (basic accident facts, location).

 

1. The names and addresses of potential negligent persons and/or entities:

 

1. The name and address of attorney representing plaintiff:

 

D.J. Banovitz, Esq.

Law Office of D.J. Banovitz, L.L.C.

7887 E> Belleview Ave. STE 1100

Englewood, CO 80111

1. The name and address of attorney representing alleged negligent parties and/or entities: Unknown at this time.

 

1. The name and address of potential negligent parties and/or entities insurance carrier or third party administrator:

 

We will keep you apprised of the claim as required. If you have any questions regarding this matter, please feel free to contact me.

Sincerely,

Law Office of D.J. Banovitz, L.L.C

D.J. Banovitz

djb/

cc: Division of Workers’ Compensation

633 17th Street

Denver, CO 80202