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Fill and Sign the Colorado Workers Compensation 497300789 Form

Fill and Sign the Colorado Workers Compensation 497300789 Form

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COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT Division of Workers’ Compensation 633 17 th St., Suite 400 Denver, CO 80202-3660 ENTRY OF APPEARANCE Claimant Workers’ Compensation Number Employer Date of Injury Insurer Claimant Social Security Number You are hereby notified that the undersigned attorney is entering his/her appearance in the above- captioned matter. I am representing the following client. (1) Claimant (2) Carrier (Name of party) (3) Dependent (Name of party) (4) Employer (Name of party) (5) Other (Name of party) Attorney (print name) Attorney Registration Number Office Code Address City State Zip Code WC6 Rev 09/06 Phone Attorney Signature WC6 Rev 09/06

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