Hearing Confirmation

C:\Users\sbarber\Downloads\WC-ConfirmationFormWord (1).docx Colorado Department of Personnel & Administration Office of Administrative Courts 1525 Sherman St., Denver, CO 80203 | www.colorado.gov/ oac Hearing Confirmation Workers222 Comp. Hearing Dates http://www.colorado.gov/oac/available-hearing-dates Today222s Date: WC No: Claimant 222s Name : Application Date: If this is a continuation of a previously held hearing, please enter the name of the presiding Judge: Is this for a Reset? Yes No Date of Hearing: Time of H r ng: Location of Hrng: Attorney or Pro Se party confirming the hearing date: First Name Last Name Staff Person submitting confirmation Email: Representing: Claimant Respondent (Specify which) I hereby certify that I mailed or delivered true and correct copies of the Hearing Confirmation t o all parties at the addresses shown below: (A claimant must provide a copy to the employer and the insurer, or their attorney.) : Party 1 First Name MI Last Name Suffix Company Address City State Zip Phone E - mail Recipient is: Party 2 First Name MI Last Name: Suffix Company Address City State Zip Phone E - mail Recipient is: NOTICE: The Office of Administrative Courts will send a Notice of Hearing to attorneys for a party in this action, and to unrepresented parties by e-mail. Please contact the Office of Administrative Courts if you have not received a copy of the notice of hearin g within 45 days of the hearing date. Signature of person submitting request Date served Rev 2/15 American LegalNet, Inc. www.FormsWorkFlow.com