State of Colorado Office of Administrative Courts

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Vs





WC #-###-###-##
A. Application for Hearing

Name of Party



Hearing Issues (At least 1 must be checked)






If the TPB or TTB are on going, please enter in the "Other Issues" section on this Application.


Witnesses to be called at the hearing or by deposition (List names and addresses)







B. Request for the OAC to Set the Matter for Hearing Rule 8(H) OACRP:

Do not fill out Section C. Complete Sections D and E.

C. Notice to Set Rule 8(F) OACRP:

to set this matter for hearing. Other parties will be called by the undersigned to confirm a date. Personnel authorized to confirm settings should be available with a calendar at that time. 

Case Name

Company

Claimant Name




D. Signature











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E. Certificate of Mailing

I hereby certify that I mailed or delivered the original of the Applicaion for Hearing and Notice to Set 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









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Employer or their Representative









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Other









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