STATE OF COLORADO Division of Workers’ Compensation Workers’ Compensation Number (s): ______________________ ____________________ ______________________ ____________________ ______________________ ____________________ IN THE MATTER OF THE CLAIM OF _____________________________________ Claimant vs PRO SE SETTLEMENT ORDER _____________________________________ Employer, [FOR UNREPRESENTED CLAIMANT] and _____________________________________ Insurer, Respondents. The parties filed a settlement agreement, with the claimant’s notarized signature dated: _________________________ ________, _____________. month day year The unrepresented claimant has: ___ seen and understands the advisement slide/video presentation or heard a prerecorded audio advisement and/or ___ has spoken with the Administrative Law Judge about this settlement ____ in person ___by telephone This approval proceeding has been electronically recorded at Tape Number_______________. IT IS ORDERED: that the parties’ settlement agreement is approved. IT IS FURTHER ORDERED: that payments to the claimant shall be made in accordance with the settlement agreement. Dated this __________ day of____________________, ___________. day month year DIVISION OF WORKERS’ COMPENSATION By____________________________________ Director or Administrative Law Judge WC 102 Rev 03/09 American LegalNet, Inc. www.FormsWorkFlow.com DIVISION CERTIFICATE OF SERVICE I hereby certify that a true and correct copy of the foregoing Order was served upon the following party by:  hand delivered on ____________________.  placing the same order in the United States mail, postage prepaid, on _______________________  placing for pick up at 633 17th Street, Suite 1300 – front desk on ___________________. This party is responsible for the timely distribution of the conformed order to all parties, pursuant to OACRP 16 G. Name Firm Name Address City, State, Zip Fax: ________________________________________ COUNSEL CERTIFICATE OF SERVICE I hereby certify that true and correct copies of the foregoing Order were served upon the parties by placing the same in the United States mail, postage prepaid on ________________________, properly addressed to the following: Interested Party 1 Address 1 City, State, Zip 1 Interested Party 2 Address 2 City, State, Zip 2 Interested Party 3 Address 3 City, State, Zip 3 ______________________________________ WC 102 Rev 03/09 American LegalNet, Inc. www.FormsWorkFlow.com