STATE OF COLORADO Division of Workers222 Compensation Workers222 Compensation Number (s): IN THE MATTER OF THE CLAIM OF Claimant vs Employer, SETTLEMENT ORDER and Insurer, Respondents. The parties filed a settlement agreement, with the claimant222s notarized signature dated: . month day year IT IS ORDERED: that the parties222 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 WORKERS222 COMPENSATION By Director or Administrative Law Judge American LegalNet, Inc. www.FormsWorkFlow.com CERTIFICATE OF I hereby certify that on the day of 20 , By: American LegalNet, Inc. www.FormsWorkFlow.com