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RESPONSE TO APPLICATION FOR HEARING

Please Note: If this is for a Worker's Compensation matter and you have a pending pre-hearing conference before the Division of Worker's Compensation, you should file any procedural motions with DoWC at the following location: 633 17th Street, 4th Floor, Denver, CO 80202

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, and

Respondent

Date of Injury

WC Number

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

Signature

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Signature

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Last Name

Suffix

Attorney Registration No

Company

Address

City

State

ZIP

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Phone Number

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

Email Address

I am the:

Contact Preference

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I accept

Certificate of Mailing

I hereby certify that I mailed or delivered the original of the for Response to Application for 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:

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