| 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.

Application for Hearing - Disfigurement Only



Vs





WC #-###-###-##
Application for Hearing - Disfigurement Only (Rule 10, OACRP)


The claimant requests a determination of additional compensation for permanent disfigurement. Section 8-42-108, C.R.S. Disfigurement will be the only issue determined at the hearing and the claimant will be the only witness, unless a response is filed adding affirmative defenses and listing additional witnesses.


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


The Office of Administrative Courts will set the matter for hearing and send a written Notice of Hearing to the parties.

Form Name

Company

Claimant Name




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. 











#####

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




Certificate of Mailing

I hereby certify that I mailed or delivered the original of the Application for Hearing - Disfigurement Only (Rule 10, OACRP) 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









#####

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


Opposing Party 2 or their Representative









#####

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


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. 


Need assistance with this form?