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PETITION TO REVIEW AND REQUEST FOR TRANSCRIPT

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

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

Transcript Request

The Petitioner requests that a transcript(s) of the hearing to be prepared and included as part of the record for the Petition to Review. If requesting a partial transcript, also indicate the approximate ending time and description.

Date of Hearing

Room, and Time the hearing began:

Date of Hearing

Room, and Time the hearing began:

Date of Hearing

Room, and Time the hearing began:

Date of Hearing

Room, and Time the hearing began:

The Petitioner requests that the Office of Administrative Courts transmit the audio recording of the hearing to the following for preparation of the transcript.

NOTICE: The Petitioner is responsible for arranging for payment of the transcript, including paying any deposit required by the court reporter or transcriptionist, and requesting an extension of time if the transcript will not be completed within 25 working days of the date the audio recording is sent to the court reporter or transcriptionist. If the original transcript is not timely filed, the request for the transcript will be stricken, a notice and briefing schedule will issue, and the transcript will not be part of the record on review.

Court reporter or transcriptionist who does not have an interest in the case:

Name

Address

City, State, ZIP

Phone, Fax, or Email

The Petitioner is indigent and has filed a Form #WC35, Application for Indigent Determination (Transcript), with the Division of Worker's Compensation

Yes

Certificate of Mailing

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.

First Name

Last Name

Suffix

Attorney Registration No.

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

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

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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