Fill and Sign the Objection Petition Colorado Form

COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT Division of Workers’ Compensation 633 17 th 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 Number Enclosed 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 17 th 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: ______ Division of Workers’ Compensation, 633 17 th St., Suite 400, Claims Section, Denver, CO 80202-3660 WC55 Rev 05/05 _ _______ 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. WC55 Rev 05/05