STATE OF COLORADO OFFICEthOF ADMINISTRATIVE COURTS 633 17 Street, Suite 1300, Denver, CO 80202 Fax: (303) 866-5909 1259 Lake Plaza Drive, Suite 230, Colo. Springs, CO 80906 Fax: (719) 576-2978 th 222 S. 6 Street, Suite 414, Grand Jct., CO 81501 Fax: (970) 248-7341 Claimant, COURT USE ONLY vs. WC NUMBER: Employer, and DATE OF INJURY: Respondent. RESPONSE TO Date of Application for Hearing APPLICATION FOR HEARING Filed by or for A. Response to Application for Hearing: (Print Name of Party) In addition to the issues marked on the Application for Hearing, the following issues shall be considered at the hearing: Compensability Medical Benefits Authorized provider Reasonably necessary Average Weekly Wage Petition to Reopen Claim Disfigurement Temporary Total Benefits from to Temporary Partial Benefits from to Permanent Partial Disability Benefits Permanent Total Disability Benefits Death Benefits Penalties: Describe with specificity the grounds on which a penalty is asserted, including the order, rule or section of the statute allegedly violated, and the dates on which you claim the violation began and ended. Other issues to be heard at this hearing are (such as maximum medical improvement, termination of benefits, etc): American LegalNet, Inc. www.FormsWorkFlow.com Witnesses to be called at the hearing or by deposition: List names and addresses: 1. 2. 3. 4. 5. 6. (Attach additional pages if necessary) D. Signature: X Signature Print/Type Name Attorney Registration Number E-Mail Address: (Failure to provide an e-mail address may result in delay in receipt of any procedural or final order) Street Address City, State, Zip Code Phone Number Date Fax Number (Optional) E: Certificate of Mailing I hereby certify that I mailed or delivered the original of the Response to Application for Hearing: Office of Administrative Courts 633 17th Street, Suite 1300 Denver, CO 80202 Office of Administrative Courts 1259 Lake Plaza Dr., Suite 210 Colorado Springs, CO 80906 Office of Administrative Courts 222 South 6th Street, Suite 414 Grand Junction, CO 81501 And copies to all parties at the addresses shown below: (A claimant must provide a copy to the employer and the insurer, or their attorney.) Claimant/Respondent or their Representative: Employer or their Representative: Other: Signature Date Mailed REV 07/11 American LegalNet, Inc. www.FormsWorkFlow.com