Fill and Sign the Personbusiness Initiating the Appeal Form

Noti ce of Appea l ICAO - WC03-2004I. AGENCY INFORMATION·Agency from which judicial review is sought: Industrial Claim Appeals Office·Agency case numberWC: ___________________ II. PROPOSED ISSUES ON APPEALPlease give ageneral andadvisory list of issues on appeal. You will be required to file a detailed opening brief 15 days after you receive notice that the record from the ICAO has been filed. If you need more space, attach a separate sheet. ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ III. PARTY AND ATTORNEY INFORMATIONAllparties and the ICAO must be identified and a copy of the notice of appeal must be mailed to each. You may refer to the mailing information on the last page of the ICAO Final Order to find this information. If a party was represented by an attorney, then you should identify the attorney and that party should be served through the attorney.Respondent Employer/Employee:Attorney for RespondentEmployer/Employee:Attorney for Respondent ICAO:Office of the Attorney General(name)(name) Human Resources Section1525 Sherman St., 5th FloorDenver, CO 80203(address)(address)Respondent Insurance CompanyAttorney for Respondent InsuranceCompany(name)(name)(address)(address)COURT OF APPEALS, STATE OF COLORADO 2 East Fourteenth Avenue, Suite 300 Denver, CO 80203_______________________________________________________ , Petitioner(Person/business initiating the appeal) V. INDUSTRIAL CLAIM APPEALS OFFICE and _______________________________________________________ , _______________________________________________________ ,Respondents(ListAll other parties to the appeal)___________________________________ Case #: _________________ (to be assigned by court)NOTICE OF APPEAL (C.A.R. 3.1Worker’s Compensation) Noti ce of Appea l ICAO - WC03-2004IV. APPENDIXYou must attach a complete copy of the ICAO Final Order, including the certificate of service. V. SIGNATUREYou must sign this notice of appeal and provide us with your address and phone number.Signature of PetitionerAddress of PetitionerBy:________________________________- Sign here -Phone #:The original and five (5) copies of this Notice of Appeal must be filed with the Clerk of the Court,Colorado Court of Appeals, 2 East 14th Ave., Suite 300, Denver, CO 80203.CERTIFICATE OF SERVICEYou must complete this certificate of service and mail or hand-deliver a complete copy of the notice of appeal to each party listed. I hereby certify that a true and correct copy of this NOTICE OF APPEAL, together with complete copies of all attachments was: placed in the United States mail, properly addressed, postage prepaid, or hand-delivered, to each of the following parties on this date: _________________________(date of mailing/hand delivery) Division of Employment & TrainingU.I. Benefits 251 East 12th Avenue Denver, CO 80203 Employer/Employee (name & address): AND Insurance Company (name & address): ANDOffice of the Attorney General Human Resources Section 1525 Sherman St., 5th Floor Denver, CO 80203 Employer’s/Employee’s Attorney, if any:By: _____________________________________ (Signature of Petitioner)Please check theappropriate box to the right.