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REQUEST FOR SPECIFIC FINDINGS OF FACT AND CONCLUSION OF LAW

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

In the Matter of the Workers' Compensation Claim of:

Claimant First Name

Claimant Last Name

Employer, and

Insurer, Respondents.

WC Number

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

A. Request for Specific Findings of Fact and Conclusions of Law

ALJ who issued the Summary Order

If Other, specify ALJ

The party dissatisfied by the Summary Order is the:

Claimant

Employer

Insurer/Respondent

Date of Service of the Summary Order

It is requested that a full order containing specific findings of fact and conclusions of law pursuant to Section 8-43-215, C.R.S..

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.

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

C. Certificate of Mailing

I hereby certify that I mailed or delivered true and correct copies of Request for Specific Findings

of Fact and Conclusion of Law for Transcript to all parties at the addresses shown below.

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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