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ENTRY OF APPEARANCE

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's First Name

Claimant's Last Name

Employer

Respondent

Date of Injury

WC Number

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

Entry of Appearance

You are hereby notified that the undersigned attorney is entering his/her appearance in the above-captioned matter before the Office of Administrative Courts, pursuant to Rule 8(G), O.A.C.R.P. I am representing the following client(s):

(1) Claimant

(Name of Party)

(2) Insurer

(Name of Party)

(3) Dependent

(Name of Party)

(4) Employer

(Name of Party)

(5) Other

(Name of Party)

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

Attorney First Name

Attorney Last Name

Suffix

Attorney Registration No

Company

Address

City

State

ZIP

#####

Phone Number

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

Email Address

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 I mailed or delivered the original of the Entry of Appearance 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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