COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT Division of Workers’ Compensation 633 17th Street, Suite 400 Denver, CO 80202-3660 PETITION TO MODIFY, TERMINATE, OR SUSPEND COMPENSATION Claimant Workers’ Compensation Number Employer Social Security Number Insurer Carrier Number The insurance carrier or self-insured employer declares that the claimant is presently receiving compensation for ___________________disability at the rate of $______________ per week. Compensation is presently being paid to _____________ in the amount totaling $______________. (date) The petitioner requests permission to modify terminate, or period from __________________ to __________________. (date) suspend compensation for the (date) The facts upon which the petitioner relies are as follows: If this matter is set for hearing, the petitioner will call the following witnesses: The rule and statute upon which the petitioner relies: NOTICE TO CLAIMANT: Rule 6-4(C) of the Workers’ Compensation Rules of Procedure, provides that if written objection to the petition is not filed with the Division of Workers’ Compensation within 20 days from the date of mailing of the petition, the Director of the Division of Workers’ Compensation shall 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 a written objection is filed, this matter will then be heard within 40 days of the date of the setting. Insurance Carrier or Self Insured Address By Certificate of Mailing (must be completed) Copies of this Petition and Objection to Petition were mailed this _____ day of _____________ ,_____ to the following: Division of Workers’ Compensation, 633 17th Street, Suite 400, Denver, CO 80202-3660 Claimant (name) (address) (name) Claimant’s Attorney (address) By Block # Adj. Code WC54 Rev 01/06 COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : INSTRUCTIONS : Index No. Calendar No. The Objection to Petition to Modify, Terminate or Suspend Compensation form must be sent to the injured worker with the : JUDICIAL SUBPOENA Plaintiff(s) Petition to Suspend. -against- : If you have any questions concerning this form, please contact the Division of Workers’ Compensation, Claims Management Section at 303.318.8600. : Please use the workers’ compensation number on all correspondence to the Division of Workers’ Compensation. : Defendant(s) : ...................................................... THE PEOPLE OF THE STATE OF NEW YORK TO GREETINGS: WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court located at County of in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the Your failure 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. Witness, Honorable Court in County, , one of the Justices of the day of , 20 (Attorney must sign above and type name below) Attorney(s) for Office and P.O. Address Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: WC 54 Rev 01/06 American LegalNet, Inc. www.USCourtForms.com