STATE OF COLORADO OFFICE OF ADMINISTRATIVE COURTS Claimant, COURT USE ONLY vs. WC NUMBER: Employer, and Respondent. CASE INFORMATION SHEET (CIS) filed by: 1. This matter is set for hearing on , in (hearing location) at (time) 2. Case Status - Check and complete, as appropriate : The parties have conferred in the last 30 days and have made a good faith effort to resolve the issues set for hearing. The parties have not conferred in the last 30 days. Is a Pre - hearing or settlement conference scheduled? Yes, on No An extension of time to commence this hearing has previously been granted. 3. DISCOVERY - Check one: Discovery has not been conducted, or discovery has been completed. Discovery has not been completed. (State briefly what discovery is incomplete, including a list of any pending motions regarding any discovery disputes: 4. STIPULATIONS TO BE OFFERED AT HEARING: 5. ISSUES REMAINING FOR DETERMINATION - Check all issues that remain: Compensability AWW (average weekly wage) Petition to Reopen TPD (temporary partial disability) Medical Benefits - Authorized provider TTD (temporary total disability) Medical Benefits - Reasonably needed PPD (permanent partial disability benefits) Disfigurement PTD (permanent total disability benefits) Death Benefits Other - Explain below or on a separate sheet: Penalties - Explain below or on a separate sheet: American LegalNet, Inc. www.FormsWorkFlow.com 6. List the lay witnesses you intend to call in your case - in - chief: Name Live or By Telephone? Will the Witness Travel Over 100 Miles? 7. List the expert witnesses you intend to call in your case - in - chief: Name Live or By Telephone? Will the Witness Travel Over 100 Miles? 8. INTERPRETER: If you will be using an interpreter, please state the interpreter222s name, or the name of the agency providing the interpreter, and the language: 9. Estimated length of time to complete your direct examination of witnesses at the hearing: 10. Signature : X Signature Attorney Registration Number First Name MI Last Name: Suffix E - mail Representing CERTIFICATE OF SERVICE I hereby certify that I mailed or delivered true and correct copies of Case Information Sheet (CIS) to all parties at the addresses shown below. Opposing Party 1 or their Representative First Name MI Last Name: Suffix Company Address City State Zip Phone E - mail Representing Opposing Party 2 or their Representative: First Name MI Last Name: Suffix Company Address City State Zip Phone E - mail Representing Signature Date Mailed REV 3/15 American LegalNet, Inc. www.FormsWorkFlow.com