COURT OF APPEALS, STATE OF COLORADO 101 West Colfax Ave., Suite 800 Denver, CO 80202 _____________________________________________ , Petitioner (Person/business initiating the appeal) V. INDUSTRIAL CLAIM APPEALS OFFICE and _______________________________________________ , _______________________________________________ , _________________________ Respondents (List All other parties to the appeal) Case #: _________________ (to be assigned by court) NOTICE OF APPEAL (C.A.R. 3.1 Workers’ Compensation) I. AGENCY INFORMATION • Agency from which judicial review is sought: Industrial Claim Appeals Office (ICAO) • Agency case number WC: ___________________ American LegalNet, Inc. www.FormsWorkFlow.com II. ISSUES ON APPEAL You must indicate below whether this document will serve as an opening brief or whether you will be filing a separate opening brief that would be due 15 days after the record is filed with the Court. If neither option is selected, the Court will presume that a separate opening brief will be filed, and your appeal may be dismissed without further notice if a separate opening brief is not filed on time. If you select the first option, you will not need to file a separate opening brief, and your appeal cannot be dismissed for failure to file such a brief. Whether or not you file a separate opening brief, in reviewing your appeal, the Court will consider only: (1) arguments that you made to the ICAO Panel, and (2) documents presented to the hearing officer and factual statements based on testimony before the hearing officer. If your appeal concerns your failure to appear at a hearing or the untimely filing of your appeal to the ICAO Panel, the Court will only consider the written explanation(s) originally provided. __ THIS NOTICE OF APPEAL WILL SERVE AS MY OPENING BRIEF. I WILL NOT BE FILING A SEPARATE OPENING BRIEF. I AM EXPLAINING BELOW THE LEGAL OR FACTUAL ISSUES I WANT THE COURT TO DECIDE. I UNDERSTAND THAT THE COURT WILL CONSIDER ONLY THE ISSUES RAISED HERE IN THIS FORM. (IF MORE SPACE IS NEEDED, PLEASE ATTACH A SEPARATE SHEET OF PAPER TO THIS FORM WITH MORE DETAILS ABOUT YOUR CASE.) __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __ I WILL BE FILING A SEPARATE OPENING BRIEF 15 DAYS AFTER THE COURT PROVIDES NOTICE THAT THE RECORD HAS BEEN FILED. I UNDERSTAND THAT BY CHOOSING THIS OPTION, MY APPEAL MAY BE DISMISSED WITHOUT FURTHER NOTICE IF A SEPARATE OPENING BRIEF IS NOT FILED ON TIME. American LegalNet, Inc. www.FormsWorkFlow.com III. PARTY AND ATTORNEY INFORMATION All parties and the ICAO must be identified and a copy of this notice of appeal must be mailed to each. You may refer to the mailing information on the last page of the ICAO Final Order to find this information. If a party was represented by an attorney, then you should identify the attorney and mail a copy of this notice of appeal to the attorney. Respondent Employer/Employee: Attorney for Respondent: (name) (name) (address) Attorney for Respondent ICAO: Office of the Attorney General State Services Section 1525 Sherman St., 7th Floor Denver, CO 80203 (address) IV. APPENDIX You must attach a complete copy of the ICAO Final Order, including the certificate of service (notice showing the date of mailing). V. SIGNATURE You must sign this notice of appeal and provide us with your address and phone number. Signature of Petitioner By:________________________________ - Sign here Phone #: Address of Petitioner The original and five (5) copies of this Notice of Appeal must be filed with the Clerk of the Court, Colorado Court of Appeals, 101 W. Colfax Ave., Suite 800, Denver, CO 80202. American LegalNet, Inc. www.FormsWorkFlow.com CERTIFICATE OF SERVICE You must complete this certificate of service and mail or hand-deliver a complete copy of this notice of appeal to each party listed. I hereby certify that a true and correct copy of this NOTICE OF APPEAL, together with complete copies of all attachments was: placed in the United States mail, properly addressed, postage prepaid, or hand-delivered to each of the following parties on this date: ________________________ (date of mailing/hand delivery) Office of the Attorney General State Services Section 1525 Sherman St., 7th Floor Denver, CO 80203 Employer’s/Employee’s Attorney, if any: By: _____________________________________ (Signature of Petitioner) American LegalNet, Inc. www.FormsWorkFlow.com