| 1 JDF 658 - General Caption (ICAO) Last Revised: , 2017 Colorado Court of Appeals 2 East 14th Avenue Denver, CO 80203 Appeal from: Industrial Claim Appeals Office (ICAO) Docket/Case Number: Petitioner: , v. Respondent(s): Industrial Claim Appeals Office, and Filing Party Name: Street Address: City: State: Zip: Phone: E-Mail: !FOR COURT USE ! Court of Appeals Case Number: Title: American LegalNet, Inc. www.FormsWorkFlow.com | 2 JDF 658 - General Caption (ICAO) Last Revised: 4, 2017 Dated: Respectfully submitted, Signature: Print Name: American LegalNet, Inc. www.FormsWorkFlow.com | 3 JDF 658 - General Caption (ICAO) Last Revised: 4, 2017 Certificate of Service I certify that on (date) , I { mailed}, or { hand delivered} this (title of document) to the Court of Appeals and mailed copies to the people listed below: (You must send a copy to each party. If a party has a lawyer, send the copy to the lawyer) Industrial Claim Appeals Office 633 17th St., Suite 00 Denver, CO 80202-3660 Colorado Attorney General 1300 Broadway, 6th Floor Denver, Colorado 80203 Other Parties (For example, the employer if you are the claimant, or claimant if you are the employer): Name of Person Served: Street Address: City: State: Zip: Space for other parties served: Signature: Print Name: American LegalNet, Inc. www.FormsWorkFlow.com