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HEARING CANCELLATION

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

WC No:

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

Hearing Date:

Hearing Time

AM or PM

Hearing Location

Attorney or Pro Se Party requesting the cancellation:

First Name

Last Name

I am the:

If Respondent or Respondent Attorney, specify which one

Name of person submitting this request (if different from the above):

Email Address

Cancellation Information

Check here to certify that you have conferred with the opposing party and that they agree to cancel this hearing:

Parties Agree

Reason for Cancellation:

Issue(s) ResolvedCase SettledApplication Withdrawn

Certificate of Mailing

I hereby certify that I mailed or delivered the original of the Hearing Cancellation 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.

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