Save my progress and resume later | Resume a previously saved form

Resume Later

In order to be able to resume this form later, please enter your email and choose a password.

Your Email:

A Password:

Confirm Password:

APPLICATION FOR EXPEDITED HEARING

Office of Administrative Courts

1525 Sherman, 4th Floor, Denver, CO 802032864 S. Circle Drive, Ste 810, Colorado Springs, CO 80906222 S. 6th St., Suite 414, Grand Jct., CO 81501

Claimant First Name

Claimant Last Name

Employer

Respondent

Date of Injury

WC Number

WC #-###-###-##

Application for Expedited Hearing

Complete Section A, B, C, D, E or F.

A. The Respondents have filed a Notice of Contest within the previous 45 days on

(date)

and the claimant requests an expedited hearing on compensability and medical benefits. (Attach a copy of the Notice of Contest). Section 8-43-203(1)(a), C.R.S.; or

Attach Notice of Contest:

B. There is an urgent need for prior authorization of health care services, as recommended in writing by

, an authorized treating provider, and prior authorization has been denied. (Attach a copy of the recommendation of the authorized treating provider). The claimant requests an expedited hearing. Rule 16-10, WCRP; or

Attach copy of recommendation

C. The Respondents have filed a Petition to Suspend, Modify, or Terminated Compensation on

(date)

and the claimant filed an objection to the Petition on

(date)

. The Respondents request an expedited hearing. (Attach a copy of the Petition and objection). Rule 6-4, WCRP.

Attach petition here:

D. The Claimant provided the Employer with notice of an alleged injury or injuries within the previous 45 days on

(Date)

The

request an expedited hearing on the issue of whether the Employer or Insurer provided a list of medical providers/physicians in compliance with section 8-43-404(5), C.R.S.

E. The Insurer or Self-Insured Employer filed an initial admission of liability for the claim within the previous 45 days on

Date

The

request an expedited hearing on the issue of whether the Employer or Insurer provided a list of medical providers/physicians in compliance with section 8-43-404(5), C.R.S.

F. The Insurer or Self-Insured Employer admitted liability within the previous 45 days on

Date

which included a reduction for compensation pursuant to section 8-42-112, C.R.S.

request an expedited hearing on the issue of whether the Employer or Insurer may reduce compensation.

The opposing party may file a response to this Application for Expedited Hearing within 10 days of the mailing or delivery of this Application for Expedited Hearing.

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

Witness 1

Witness 2

Witness 3

Witness 4

Witness 5

Witness 6

Attach additional witness pages as necessary

Case Name

Is the Claimant an individual or a Company?

IndividualCompany

Company

Claimant Name

First Name

Last Name

Suffix

Signature

Please type your name in the box below. By typing your name, you certify this information is accurate and certify that this will act as your binding electronic signature.

Signature

First Name

Last Name

Suffix

Attorney Registration No

Company

Address

City

State

ZIP

#####

Phone Number

###-###-####

Email Address

I am the:

Contact Preference

You have selected traditional mail as your preferred contact method. This may result in delay in receipt of any procedural or final order. If you accept these terms, please check below. If you do not, please select "Email."

I accept

Certificate of Mailing

I hereby certify that I mailed or delivered the original of the Application for Expedited Hearing to all parties at the addresses shown below (A claimant must provide a copy to the employer and the insurer, or their attorney):

Opposing Party 1 or their Representative

First Name

Last Name

Suffix

Company

Address

City

State

ZIP

#####

Phone Number

###-###-####

Email Address

Recipient is the:

Opposing Party 2 or their Representative

First Name

Last Name

Suffix

Company

Address

City

State

ZIP

#####

Phone Number

###-###-####

Email Address

Recipient is the:

Please type your name in the box below. By typing your name, you certify this information is accurate and certify that this will act as your binding electronic signature.

Certificate of Service Signature

Date Served:

To attach additional recipients of this pleading, please click here.

Save my progress and resume later | Resume a previously saved form

Need assistance with this form?