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CASE INFORMATION SHEET (CIS)

Office of Administrative Courts

1525 Sherman St., 4th Floor, Denver, CO 802022864 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, and

Respondent

CASE INFORMATION SHEET (CIS) filed by:

WC Number:

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

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

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 Case Information Sheet (CIS) 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

Middle Initial

Last Name

Suffix

Company

Address

City

State

ZIP

#####

Phone Number

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

Email Address

Recipient is the:

Opposing Party 2 or their Representative

First Name

Middle Initial

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.

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Compensability	Petition to Reopen
Medical Benefits - Authorized Provider	Medical Benefits - Reasonably Needed
Disfigurement	Death Benefits
AWW (Average Weekly Wage)	PPD (Perm. Partial Disability)
PTD (Perm. Total Disability)	TPD (Temp. Partial Disability)
TTD (Temp. Total Disability)	Penalties
Other

Witness 1 Name	Live or By Telephone?	Will the witness travel over 100 miles?
Witness 2 Name	Live or By Telephone?	Will the witness travel over 100 miles?
Witness 3 Name	Live or By Telephone?	Will the witness travel over 100 miles?

Expert 1 Name	Live or By Telephone?	Will the witness travel over 100 miles?
Expert 2 Name	Live or By Telephone?	Will the witness travel over 100 miles?
Expert 3 Name	Live or By Telephone?	Will the witness travel over 100 miles?