STATE OF COLORADO DIVISION OF WORKERS222 COMPENSATION W.C. No(s): Carrier No(s): MOTION TO CLOSE CLAIM FOR FAILURE TO PROSECUTE IN THE MATTER OF THE WORKERS222 COMPENSATION CLAIM(S): ,Claimant, v. ,Employer, and , Carrier/Self-Insured , Insurer/Respondents. The Respondent(s), pursuant to Rule 7-1(C) of the Workers222 Compensation Rules of Procedure, move that the Director close this claim on the ground that there has been no activity in furtherance of prosecution of this claim in the past six months. Specific facts supporting closure are: WHEREFORE, Respondent(s) move that this claim be closed for failure to prosecute. Dated: Respectfully submitted, By: (Name) (Address and telephone number) American LegalNet, Inc. www.FormsWorkFlow.com W.C. #: RE: CERTIFICATE OF MAILING: I hereby certify that on this day of , , a true and correct copy of the foregoing MOTION TO CLOSE CLAIM FOR FAILURE TO PROSECUTE, was placed in the U.S. mail, postage prepaid and properly addressed to: Claimant Name: Address: City / State / Zip: Claimant222s Attorney: Address: City / State / Zip: Carrier or Self-Insured: Address: City / State / Zip: Carrier222s Attorney: Address: City / State / Zip: Other (please specify): Original: Division of Workers222 Compensation 633 17th St., Suite 400 Denver, CO 80202 By: American LegalNet, Inc. www.FormsWorkFlow.com STATE OF COLORADO DIVISION OF WORKERS222 COMPENSATION W.C. No(s): Carrier No(s): ORDER TO SHOW CAUSE IN THE MATTER OF THE WORKERS222 COMPENSATION CLAIM(S): ,Claimant, v. ,Employer, and , Carrier/Self-Insured , Insurer/Respondents. Notice to Claimant: The Division of Workers222 Compensation has received a request from your employer or workers222 compensation insurance carrier that your case be closed since there has been no activity on your claim for the last six months. 1)You must tell the Division of Workers222 Compensation what recent effort you have made or aremaking to pursue your claim for workers222 compensation benefits and why you think your claimshould remain open. You must show good cause as to why your claim should not be closed. Thismust be done in writing, and you must send a copy to the employer and insurance carrier. 2)If you did not already send a response to the request to close your claim, or if you do not mail ordeliver a response within thirty (30) days of the date of the Certificate of Mailing attached to thisOrder, your claim will be automatically closed. Your written response must be filed with theDirector, at the Division of Workers222 Compensation, 633 17th Street, Suite 400, Denver, CO 80202. 3)The closure of your claim will not affect ongoing benefits which have been admitted by theemployer, the insurer (such as medical benefits after maximum medical improvement), or whichhave been ordered by an Administrative Law Judge. 4)If your case is closed after 30 days, you have the right to petition to reopen your claim, subject tothe provisions of 247 8-43-303 C.R.S. IT IS, THEREFORE, ORDERED: That if a response has not already been submitted or is not mailed or delivered to the Division within thirty (30) days showing good cause why this claim should remain open, it will be automatically closed. Dated: DIVISION OF WORKERS222 COMPENSATION BY OR FOR THE DIRECTOR American LegalNet, Inc. www.FormsWorkFlow.com W.C. #: RE: CERTIFICATE OF MAILING: I hereby certify that on this day of , , a true and correct copy of the foregoing ORDER TO SHOW CAUSE, was placed in the U.S. mail, postage prepaid and properly addressed to: Claimant Name: Address: City / State / Zip: Claimant222s Attorney: Address: City / State / Zip: Carrier or Self-Insured: Address: City / State / Zip: Carrier222s Attorney: Address: City / State / Zip: Other (please specify): Original: Division of Workers222 Compensation 633 17th St., Suite 400 Denver, CO 80202 By: American LegalNet, Inc. www.FormsWorkFlow.com