1 STATE OF COLORADO OFFICE OF ADMINISTRATIVE COURTS Choose an item. 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. 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. X Signature Attorney Registration Number First Name MI Last Name: Suffix Company Address City State Zip Phone E - mail American LegalNet, Inc. www.FormsWorkFlow.com 2 I hereby certify that I mailed or delivered true and correct copies of the APPLICATION FOR HEARING - DISFIGUREMENT ONLY (RULE 10, OACRP) to 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 the: Party 2 First Name MI Last Name Suffix Company Address City State Zip Phone E - mail Recipient is the: Signature of person serving document Date served Rev 3 /1 7 American LegalNet, Inc. www.FormsWorkFlow.com