Colorado > Workers Comp
Application For Hearing And Notice To Set - Colorado
| Application For Hearing And Notice To Set Form. This is a Colorado form and can be used in Workers Comp . |
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STATE OF COLORADO OFFICE OF ADMINISTRATIVE COURTS th 633 17 Street, Suite 1300, Denver, CO 80202 Fax: (303)866-5909 1259 Lake Plaza Drive, Suite 230, Colo. Springs, CO 80906 Fax: (719) 576-2978 th 222 S. 6 Street, Suite 414, Grand Jct., CO 81501 Fax: (970)248-7341 Claimant, COURT USE ONLY vs. WC NUMBER: Employer, and DATE OF INJURY: Respondent. APPLICATION FOR HEARING AND NOTICE TO SET A. Application for Hearing: Filed by or for (Print Name of Party) It is requested that this matter be set for hearing in (check one): Alamosa Denver Durango Glenwood Spgs Grand Jct. Greeley Colorado Springs Loveland Pueblo Check here to certify that you have attempted to resolve with the other parties all issues listed on the application for hearing (Section 8-43-211(2)(e), C.R.S.) Check here if compensability is contested, or if this hearing is requested in response to a final admission of liability or to contest a conclusion in a Division sponsored independent medical examination. The following issues shall be considered at the hearing: Compensability Medical Benefits Authorized provider Reasonably necessary Average Weekly Wage Petition to Reopen Claim Disfigurement Temporary Total Benefits from to Temporary Partial Benefits from to Permanent Partial Disability Benefits Permanent Total Disability Benefits Death Benefits Penalties: Describe with specificity the grounds on which a penalty is asserted, including the order, rule or section of the statute allegedly violated, and the dates on which you claim the violation began and ended. Other issues to be heard at this hearing are (such as maximum medical improvement, termination of benefits, etc): C:\Documents and Settings\CHILDERD\Desktop\AppHrg.doc Witnesses to be called at the hearing or by deposition: List names and addresses: 1. 2. 3. 4. 5. 6. (Attach additional pages if necessary) B. Request for the OAC to Set the Matter for Hearing Rule 8(H) OACRP: If you are not represented by an attorney and would like the Office of Administrative Courts to set this case for you, please check here: Do not fill out Section C. Complete Sections D and E. Notice to Set Rule 8(F) OACRP: C. A setting date shall be on a Tuesday, Wednesday, or Thursday, between the hours of 8:00 am to 12:00 noon or 1:00 pm to 3:00 pm, at least ten days and no more than twenty days after this APPLICATION FOR HEARING AND NOTICE TO SET has been mailed. The undersigned will contact the Office of Administrative Courts, at http://www.colorado.gov/dpa/oac/WCSet.htm, or (303) 866-5881 on the day of , 20 at : .M., to set this matter for hearing. Other parties will be called by the undersigned to. confirm a date. Personnel authorized to confirm settings should be available with a calendar at that time. D. Signature: X Signature Print/Type Name Attorney Registration Number Street Address City, State, Zip Code Phone Number Fax Number (Optional) E-Mail Address: (Failure to provide an e-mail address may result in delay in receipt of any procedural or final order) Date E: Certificate of Mailing I hereby certify that I mailed or delivered the original of the Application for Hearing and Notice to Set to: Office of Administrative Courts 633 17th Street, Suite 1300 Denver, CO 80202 Office of Administrative Courts 1259 Lake Plaza Dr., Suite 230 Colorado Springs, CO 80906 Office of Administrative Courts 222 South 6th Street, Suite 414 Grand Junction, CO 81501 And copies to all parties at the addresses shown below: (A claimant must provide a copy to the employer and the insurer, or their attorney.) Claimant/Respondent or their Representative: Employer or their Representative: Other: Signature Date Mailed REV 12/07 C:\Documents and Settings\CHILDERD\Desktop\AppHrg.doc
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