Download Heart and Circulatory Malfunction Claim Form

Department of Finance
Cash, Risk and Capital Funding
Workers’ Compensation Unit
201 West Colfax Avenue, Department 1105
Denver, CO 80202
p: 720.913.3330
f: 720.913.3184
www.denvergov.org/Finance
CLAIM FORM FOR HEART AND CIRCULATORY MALFUNCTION BENEFITS
1.
Firefighter’s Name:___________________________________
4.
Date of Birth: ___/___/____ 3. Employee Number_________4. Social Security Number: _____-___-_____
5.
Date of Hire:___/___/___
6.
Home Address:_____________________________
7.
City_____________________ 8. State:____ 9. Zip: _________
10.
Date of Work Event:___/___/___
11.
Description of Work Event:_____________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
12.
Date and Nature of Heart and Circulatory Malfunction:_____________________________________
____________________________________________________________________________________
____________________________________________________________________________________
13.
14.
15.
Date of Release From Hospital (if applicable): ___/___/___
Date of medical examination prior to the Heart and Circulatory Malfunction:___/___/___
Name and Address of medical provider for question 14:_________________________________________
_________________________________________________________________________________
Please attach page(s) with any additional information you feel is necessary to or that you wish to share as part of
the process of investigating and handling your claim for benefits.
Instructions for completing the Claim Form for Heart and Circulatory Malfunction benefits:
The “Heart and Circulatory Malfunction Benefit” act was passed by the Colorado legislature in 2014,
signed into law by the Governor, and took effect as of January 1, 2015. The purpose of this law is to
provide employer-paid benefits to a Firefighter for cardiac illnesses resulting from a strenuous work
event. The eligibility for these benefits does not arise from an “unusual exertion” as is required for
eligibility for benefits under Colorado Workers’ Compensation law.
A completed claim form is required to be delivered (via mail, interoffice mail, fax or E-Mail) to the
City’s Risk Management department no later than 10 days after the onset of a Heart and Circulatory
Malfunction caused by a Work Event, or if hospitalization resulted from this event, no later than 10 days
after release from the hospital.
Risk Management will initiate a Workers’ Compensation claim and investigate potential eligibility for
Workers’ Compensation benefits for any firefighter who submits a completed Heart and Circulatory
Malfunction Claim form, in addition to determining eligibility for benefits under the Heart and
Circulatory Malfunction Benefits act/law. If the firefighter is eligible for Workers’ Compensation
Temporary wage loss, disfigurement and/or permanency benefits, those benefits are offset against any
benefits a firefighter is eligible for under the Heart and Circulatory Malfunction act/law. Benefits
payable from the Fire and Police Pension Association, Social Security and/or any income benefit paid
for by the City will also be offset against any benefit payable under the Heart and Circulatory
Malfunction act/law.
Questions 1-10 of the Claim Form request basic information such as name, address, employee and social
security numbers, the date of hire and the date of the heart and circulatory malfunction. To be eligible, a
firefighter must have at least 5 years of continuous, full-time employment with the City and County of
Denver and must regularly work at least 1,600 hours in any calendar year at duties directly involved in
the provision of fire protection services.
Question 11 asks the description of the “work event” that led to the heart and circulatory malfunction.
“Work event” is defined in the act/law as “stressful or strenuous activity related to fire suppression, rescue,
hazardous material response, emergency medical services, disaster relief, or other emergency response
activity. "Work event" includes a training activity that a firefighter engages in while on duty and that
involves stressful or strenuous activity.”
Question 12 asks the date and description of the “heart and circulatory malfunction”. This term is defined
in the act/law as, “a sudden and serious malfunction of the heart and circulatory system as occurs in a
diagnosis of coronary thrombosis, cerebral vascular accident, myocardial infarction, or cardiac arrest and
that meets the requirements of section 29-5-302 (6). "Heart and circulatory malfunction" does not include
hypertension or angina.”
Question 13 asks the date of release from a hospital following treatment for a heart and circulatory
malfunction, if applicable.
Questions 14 and 15 ask the date and the name/address of the medical provider who performed the most
recent medical examination prior to the onset of a heart and circulatory malfunction.
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