Save my progress and resume later | 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.

Your Email:

A Password:

Confirm Password:

PETITION TO REVIEW

In the Matter of the Workers' Compensation Claim of:

Claimant First Name

Claimant Last Name

Employer, and

Insurer, Respondents.

Case Number

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

TO THE DENVER OFFICE OF ADMINISTRATIVE COURTS

The

Claimant

Employer

Insurance Carrier

petitions to review the order of theAdministrative Law Judge

Other ALJ

mailed or served on

*No transcript is needed.

Petitioner objects to the Findings of Fact, Conclusions of Law, and Order of the ALJ on the following ground(s):

Set forth in detail the particular alleged errors and your objections to the order.

Attach additional pages as necessary

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.

Signature

First Name

Last Name

Suffix

Attorney Registration Number

Company

Address

City

State

ZIP

#####

Phone Number

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

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 a true and correct copy of this document has been delivered to the ALJ and to the following parties, at the addresses shown and on the date below:

This Petition to Review must be filed with the Denver Office of Administrative Courts. A Petition to Review filed in another office of the OAC will not be accepted for filing.

Office of Administrative Courts

1525 Sherman, 4th Floor

Denver, CO 80203

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.

Save my progress and resume later | Resume a previously saved form

Need assistance with this form?