COLORADO DEPARTMENT OF LABOR & EMPLOYMENT DIVISION OF WORKERS' COMPENSATION COURT NOTICE OF FAILED IME NEGOTIATION COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. The insurance carrier must submit this form to the Division as notification that the parties have failed in their : Calendar No. attempt to negotiate the selection of an IME physician. Plaintiff(s) : JUDICIAL SUBPOENA WC # Claimant Name Carrier Claim # -against- Social Security # : : Date of Injury I hereby notify the Division that on this the parties were unable to agree upon a physician. Signature day of : , Defendant(s) : ...................................................... Date Name of Signer THE PEOPLE OF THE STATE OF NEW YORK TO Carrier Name CERTIFICATE OF MAILING: Copies of this document were placed in the U.S. mail or delivered to the following parties this day of , GREETINGS: List the names and address of all persons copied: Name Address WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court Claimant: located at County of Claimant's Attorney:room in , on the day of , 20 , at o'clock in the noon, and at any recessed Employer: or adjourned date, to testify and give evidence as a witness in this action on the part of the Carrier's Attorney: Division of Workers' Compensation, 633 17th Street, Suite 400, Denver, CO 80202-3660 By: Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whoseAdjustor's Signature was issued for a maximum penalty of $50 and all damages sustained as a behalf this subpoena result of your failure to comply. Witness, Honorable County, NOTICES day of , 20 , one of the Justices of the Court in NOTICE TO CARRIER: The carrier shall submit this notice within 30 days from the date of disagreement of the parties. (Attorney must sign above and type name below) NOTICE TO REQUESTING PARTY: This notice does not eliminate the requirement that the requesting party submit an Application for a Division Independent Medical Examination (IME) form. Submit the Application to the Division and to all parties within 30 days from the date of disagreement. Attorney(s) for If you have any questions about the IME process, contact the Division of Workers' Compensation IME Unit. Division of Workers' Compensation and P.O. Address Office IME Unit 633 17th Street, Suite 400 Denver, CO 80202-3660 Telephone No.: 303.318.8655 Facsimile No.: Toll Free: 888.390.7936 E-Mail Address: Mobile Tel. No.: WC165 05/05 I . American LegalNet, Inc. www.USCourtForms.com