Fill and Sign the 633 17th St Form

Block #Adj. CodeWC54 Rev 01/06 COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT Division of Workers’ Compensation633 17th St., Suite 400, Claims Section Denver, CO 80202-3660 PETITION TO MODIFY, TERMINATE, OR SUSPEND COMPENSATION Claimant Workers’ Compensation Number Employer Social Security Number Insurer Carrier Number The insurance carrier or self-insured employer declares that the claimant is presently receiving compensation for ___________________disability at the rate of $______________ per week. Compensation is presently being paid to _____________ in the amount totaling $______________. (date) The petitioner requests permission to modify terminate, or suspend compensation for the period from __________________ to __________________. (date) (date) The facts upon which the petitioner relies are as follows:If this matter is set for hearing, the petitioner will call the following witnesses:The rule and statute upon which the petitioner relies:NOTICE TO CLAIMANT: Rule 6-4(C) of the Workers’ Compensation Rules of Procedure provides that if written objection to the petition is not filed with the Division of Workers’ Compensation within 20 days from the date of mailing of the petition, the Director of the Division of Workers’ Compensation may 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 a written objection is filed, this matter will then be heard within 40 days of the date of the setting. Insurance Carrier or Self Insured Address By Certificate of Mailing (must be completed) Copies of this Petition and Objection to Petition were mailed this _____ day of _____________ ,_____ to the following:Division of Workers’ Compensation, 633 17th St., Suite 400, Claims Section, CO 80202-3660ClaimantClaimant’s Attorney (name) (address) (name)(address) By INSTRUCTIONS The Objection to Petition to Modify, Terminate or Suspend Compensation form must be sent to the injured worker with the Petition to Suspend.If you have any questions concerning this form, please contact the Division of Workers’ Compensation, Claims Management Section at 303.318.8600.Please use the workers’ compensation number on all correspondence to the Division of Workers’ Compensation.WC54 Rev 01/06