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 210, 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 - DISFIGUREMENT ONLY (RULE 10, OACRP) The claimant requests a determination of additional compensation for permanent disfigurement. Section 8-42-108, C.R.S. Disfigurement will be the only issue determined at the hearing and the claimant will be the only witness, unless a response is filed adding affirmative defenses and listing additional witnesses. Check here to certify that you have attempted to resolve the issue of disfigurement with the respondent(s). (Section 8-43-211(2)(e), C.R.S.) The opposing party may file a response to this Application for Hearing - Disfigurement Only within 10 days of the mailing or delivery of this Application for Expedited Hearing. The Office of Administrative Courts will set the matter for hearing and send a written Notice of Hearing to the parties. D. Signature: X Signature Street Address Print/Type Name City, State, Zip Code Attorney Registration Number 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 American LegalNet, Inc. www.FormsWorkflow.com 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 210 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 REV12/07 American LegalNet, Inc. www.FormsWorkflow.com