COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT Division of Workers’ Compensation 633 17th Street, Suite 400 Denver, CO 80202-3660 COURT OBJECTION TO PETITION TO MODIFY, TERMINATE, OR SUSPEND COMPENSATION COUNTY OF ...................................................... : Index No. ___________________________________________ ___________________________________________ Claimant Workers’ Compensation Number : Calendar No. ___________________________________________ Employer ___________________________________________ Insurer -against- ___________________________________________ : Social Security Number JUDICIAL SUBPOENA Plaintiff(s) ___________________________________________ Carrier Number : : Enclosed is a copy of the Petition to Modify, Terminate, or Suspend Compensation filed by the insurance carrier or selfinsured employer in your worker’s compensation case. : Defendant(s) : IN THE EVENT THAT. YOU . . . . . . .TO. OBJECT .TO. THIS .PETITION, . . . . . .MUST FILE A WRITTEN OBJECTION WITH . . . . . . . WISH . . . . . . . . . . . . . . . . . . . . . . . . . . . YOU . . THE DIVISION OF WORKERS’ COMPENSATION, 633 17TH STREET,SUITE 400, DENVER, CO 80202-3660, WITHIN 20 DAYS FROM THE DATE THE PETITION WAS MAILED. YOUR OBJECTION MUST BE FILED ON THIS FORM. A copy must be sent to the insurance carrier or the self-insured employer at the address shown on the petition. THE PEOPLE OF THE STATE OF NEW YORK In the event that you do not file a written objection to the petition within the required 20 days, the Director of the Division of TO Workers’ Compensation will grant the insurance carrier or self-insured employer permission to modify, terminate or suspend compensation as of the date of the petition. In the event that you do object to the petition, a hearing will be held on the petition within 40 days of the date of the setting. GREETINGS: The only matter which will be considered at this hearing will be the request to modify, terminate, or suspend compensation. WE COMMAND YOU, that OBJECTION TO PETITION aside, you and each of you attend before CLAIMANT’S all business and excuses being laid , the Honorable at the Court I object to the Petition to of Suspend County Modify, Terminate, or located at Compensation filed by the insurance carrier or self-insured employer. I requestin room matter ,be set for hearing on this issue. Theat that this for my objections are: at any recessed on the day of , 20 , reasonso'clock in the noon, and ___________________________________________________________________________________________________ or adjourned date, to testify and give evidence as a witness in this action on the part of the ___________________________________________________________________________________________________ Your failure hearing on this issue: I will call the following witnesses at the to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as ___________________________________________________________________________________________________a result of your failure to comply. ________________________________________________ Signature Witness, Honorable , one of the Justices of the Court in County, day of , 20 ________________________________________________ Address CERTIFICATE OF MAILING (Attorney must sign above and type name below) Copies of this Objection to Petition were mailed this ________day of ______________________, ________ to the following: _______ _______ Division of Workers’ Compensation, 633 17th Street, Suite 400, Denver, CO 80202-3660 Attorney(s) for Insurance Carrier or_________________________________________________________________________ Self-Insured Employer (name) (address) Office and P.O. Address By _____________________________________________ Claimant If you have any questions concerning this form, please contact the Division of Workers’ Compensation, Claims Management Telephone No.: Section 303.318.8600. Facsimile No.: Please use your worker’s compensation number on all correspondence to the Division of Workers’ Compensation. E-Mail Address: Mobile Tel. No.: WC55 Rev 05/05 I American LegalNet, Inc. www.USCourtForms.com