COURT COUNTY .OF. . . . . . . . . . . . . . . . .PETITION. TO .REOPEN ......... .. ........... .... ........ : Index No. Claimant WC# Claimant’s Address : Carrier Claim # : Plaintiff(s) JUDICIAL SUBPOENA Social Security # -against- Claimant’s Phone # Calendar No. : Date of Injury Insurance: Carrier Employer : This matter should be reopened because: Defendant(s) : Change . . .medical. condition. . . Attach.documentation . . . . . . . . . . . . . . . in . . . . . . . . . . . . . . - . . . . . . . . . . . . . . . . . Error - Attach documentation Mistake PEOPLE documentation OF NEW YORK THE - Attach OF THE STATE Fraud - Attach documentation TO Overpayment - Attach calculations Terminate Permanent Total Benefits - Attach statement GREETINGS: WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Claimant Employer Insurance Carrier , the Honorable at the Court located at County of Signature of Requester _________________________________________ Date Signed ________________________ 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 Requester: (Please check one) CERTIFICATE OF MAILING Copies of this document were placed in the U.S. mail or delivered to the following parties this _________ day of _______________________________, ____________. Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to List names and addresses of all persons copied: was issued for a maximum penalty of $50 and all damages sustained as a Name Address the party on whose behalf this subpoena Claimant: result of your failure to comply. Claimant’s Attorney: Witness, Honorable Employer: Court in County, , one of the Justices of the day of , 20 Carrier: Carrier’s Attorney: (Attorney must sign above and type name below) By: ___________________________________________________________________ (Signature) Attorney(s) for This petition must be provided to the other party and to all attorneys of record. The petition must state the basis for the reopening, and supporting documentation must accompany the request. Once a petition has been filed, the requester may apply for a hearing before an Administrative Law Judge. To request a hearing, contact the Office of Administrative Office and P.O. Address Courts at 303.866.2000 and request an APPLICATION FOR HEARING form. WC37 Rev 01/06 Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com PETITION TO REOPEN INSTRUCTIONS Please read the following instructions carefully. This form must be complete so that the opposing party* has the information COURT to consider your request. Please type or neatly print, and then sign the form. You may want to use the last Final Admission COUNTY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . of Liability filed .on .this . . .OF.or,.if .applicable,. the .final. order. to .help. you. fill out this form. Fill in all the blank lines. claim .. ... Claimant: Claimant’s Address: Claimant’s Phone #: Employer: WC#: Carrier Claim #: Social Security #: Date of Injury: Insurance Carrier: : Index No. Name of injured worker List the current address for the claimant : Calendar No. List the current phone number for the claimant : Name of employer that the injured worker was working for on the date of injury JUDICIAL SUBPOENA Plaintiff(s) Workers’ Compensation Number - refer to the carrier’s last admission Insurance-against- claim file number - refer :to the carrier’s last admission carrier’s Social Security Number - make sure number is correct for the injured worker : Date this injury occurred Name of the insurance company or self-insured employer : Check the reason or reasons for reopening the claim. If the request to reopen is based on a change in medical condition, Defendant(s) : some type of documentation . . . . . . . . . .the .change .in. condition. must.be .attached. If a medical report is submitted, it may . . . . . . . . . . . reflecting . . . . . . . . . . . . . . . . . . . . . . . . . . . include information on the following: the physical condition of the claimant at the time the petition is filed, how the condition has worsened or improved, and a statement relating the disability to the work-related accident or exposure. Documentation for any other reason checked must also be attached. THE PEOPLE OF THE STATE OF NEW YORK Check the box to indicate whether the person completing the Petition to Reopen (Requester) is the Claimant, Employer, or TO Insurance Carrier. The requester must sign and date the form. A copy of the completed form and accompanying documentation must be sent to the opposing party* and to all attorneys of record. Fill in and sign the mailing certificate at bottom of the form. List the names and addresses of all the parties to whom GREETINGS: you are mailing copies. Make sure to keep a copy for yourself. If the opposing party* does not voluntarilyYOU, that allclaim or doesexcuses being a response, you may wish to set thebefore WE COMMAND reopen the business and not provide laid aside, you and each of you attend matter for a pre-hearing the Honorable calling 303.866.5508. If issues cannot be resolved between both parties, you may request a , conference by at the Court hearing before an administrative law judge. located at To request a hearing, contact the Office of Administrative Courts at County of in room , on the , 20 , at o'clock in the 303.866.2000 and ask to have Application forday of forms sent to you. If you do not take anynoon, and at any recessed Hearing action, the status of the or adjourned either party and give reopen as a witness in insurer must notify the Division in writing or by claim remains unchanged. Ifdate, to testify agrees toevidence the claim, the this action on the part of the admission. *Note to Claimants: The opposing party in your claim is the insurance company or the self-insured employer. The address Your failure to comply with this for the opposing party is on the admission of liability. 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. REOPENING PERMANENT TOTAL DISABILITY BENEFITS: Witness, Honorable Section 8-43-303(3) of the Colorado Revised Statutes provides: , one of the Justices of the Court in County, day of , 20 In cases where a claimant is determined to be permanently totally disabled, any such case may be reopened at any time to determine if the claimant has returned to employment. If the claimant has returned to employment and is earning in excess of four thousand dollars per year or has participated in activities which indicate that the claimant has the ability to return to employment, such (Attorney must to above and type name total claimant's permanent total disability award shall cease and the claimant shall not be entitledsignfurther permanentbelow) disability benefits as a result of the injury or occupational disease which led to the original permanent total disability award. Any subsequent permanent partial disability benefits awarded for the same injury or occupational disease shall be decreased by the amount of permanent total disability benefits previously received by the employee. Attorney(s) for In the absence of an agreement with the claimant to voluntarily reopen and terminate permanent total disability benefits followed by an admission terminating the same, the insurer or self-insured employer must request a hearing before an administrative law judge should it seek to terminate these benefits. Office and P.O. Address IF YOU HAVE ANY QUESTIONS OR NEED HELP IN COMPLETING THIS FORM, CONTACT THE DIVISION OF WORKERS’ COMPENSATION, CUSTOMER SERVICE UNIT Telephone No.: 633 17TH STREET, SUITE 400, DENVER, CO 80202-3660 Facsimile No.: 303. 318.8700 OR TOLL FREE AT 888.390.7936 WC37 Rev 01/06 E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com