Fill and Sign the Suite 400 Claims Section Form

WC55 Rev 05/05 COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT Division of Workers’ Compensation633 17th St., Suite 400, Claims Section Denver, CO 80202-3660 OBJECTION TO PETITION TO MODIFY, TERMINATE, OR SUSPEND COMPENSATION __________________________________________ _Claimant__________________________________________ _Employer__________________________________________ _Insurer__________________________________________ _Workers’ Compensation Number__________________________________________ _Social Security Number__________________________________________ _Carrier NumberEnclosed is a copy of the Petition to Modify, Terminate, or Suspend Compensation filed by the insurance carrier or self- insured employer in your worker’s compensation case.IN THE EVENT THAT YOU WISH TO OBJECT TO THIS PETITION, YOU MUST FILE A WRITTEN OBJECTION WITH THE DIVISION OF WORKERS’ COMPENSATION, 633 17th ST., SUITE 400, CLAIMS SECTION, DENVER, CO 80202-3660, WITHIN 20 DAYS FROM THE DATE THE PETITION WAS MAILED. YOUR OBJECTION MUST BE FILED ON THIS FORM. A copy must be sent to the insurance carrier or the self-insured employer at the address shown on the petition.In the event that you do not file a written objection to the petition within the required 20 days, the Director of the Division of Workers’ Compensation will grant the insurance carrier or self-insured employer permission to modify, terminate or suspend compensation as of the date of the petition.In the event that you do object to the petition, a hearing will be held on the petition within 40 days of the date of the setting. The only matter which will be considered at this hearing will be the request to modify, terminate, or suspend compensation. CLAIMANT’S OBJECTION TO PETITION I object to the Petition to Modify, Terminate, or Suspend Compensation filed by the insurance carrier or self-insured employer. I request that this matter be set for hearing on this issue. The reasons for my objections are:______________________________________________________________________________________________ ___________________________________________________________________________________________________ _____I will call the following witnesses at the hearing on this issue:______________________________________________________________________________________________ ___________________________________________________ __ Signature ______________________________________________ __ Address CERTIFICATE OF MAILING Copies of this Objection to Petition were mailed this ________day of ______________________, ________ to the following: WC55 Rev 05/05______ _Division of Workers’ Compensation, 633 17th St., Suite 400, Claims Section, Denver, CO 80202-3660_______Insurance Carrier or_________________________________________________________________________Self-Insured Employer (name) (address)By _____________________________________________ Claimant If you have any questions concerning this form, please contact the Division of Workers’ Compensation, Claims Management Section 303.318.8600.Please use your worker’s compensation number on all correspondence to the Division of Workers’ Compensation.