STATE OF COLORADO

OFFICE OF ADMINISTRATIVE COURTS

1525 Sherman St., 4th Floor, Denver, CO 80203 Fax: (303) 866-5909
1259 Lake Plaza Drive, Suite 230, Colo. Springs, CO 80906 Fax: (719) 576-2978
222 S. 6th Street, Suite 414, Grand Jct., CO 81501 Fax: (970) 248-7341

JOHN Q. SMITH
Claimant,

 COURT USE ONLY 

vs.
WC NUMBER:
FIRSTFLEET, INC. 1-234-567
Employer, and

TRAVELERS INSURANCE DATE OF INJURY:

Respondent.
01/01/2017
RESPONSE TO SEPTEMBER 1, 2017 APPLICATION FOR HEARING

A. Response to Application for Hearing: Filed by or for Respondents (Print Name of Party)

In addition to the issues marked on the Application for Hearing, the following issues shall be considered at the hearing:

Compensability Temporary Total Benefits from

Medical Benefits 01/01/17 to ONGOING

Authorized provider
Reasonably necessary Temporary Partial Benefits from

Average Weekly Wage 01/01/17 to ONGOING

Petition to Reopen Claim Permanent Partial Disability Benefits

Disfigurement Permanent Total Disability Benefits

Death Benefits

Penalties: Describe with specificity the grounds on which a penalty is asserted, including the order, rule or section of the
statute allegedly violated, and the dates on which you claim the violation began and ended.

Other issues to be heard at this hearing are (such as maximum medical improvement, termination of benefits, etc):

Causation; Relatedness; Offset/s; Overpayment/s; Credit/s; Respondents deny and contest current injury
or injuries as being causally related to any work injury; Pre-existing injury; Idiopathic injury; Subsequent
aggravation; Respondents deny any change of Authorized Treating Physician; Course and scope of
employment; Sphere of employment; Termination for cause; Apportionment; no TTD or TPD benefits
are owed. Upon further investigation and discovery of this matter, Respondents may agree to withdraw or
add affirmative defenses.
Witnesses to be called at the hearing or by deposition: List names and addresses:

1. John Q. Smith, 123 Four Street, Denver, CO 80201

2. Dr. Primary Care and/or any medical provider at 567 Eight Circle, Denver, CO 80202
3. Constance Coworker, Margaret Manager, Emmy Employer and/or any representative of Employment P.C., 910 Eleven
Avenue, Denver, CO 80203
4. Dr. Sarah Specialist, 1213 Fourteen Drive, Denver, CO 80204
5. Irwin Investigator, Investigative Firm, 15 Sixteen Parkway, Denver, CO 80205
6. Iris Insurer and/or any representative of Insurance Company, 1718 Nineteen Way, Denver, CO 80206
(Attach additional pages if necessary)

D.

X /s/ Leslie L. Lawyer, Esq. 1 17th Street

Signature Street Address
Leslie L. Lawyer, Esq. Denver, CO 80201
Print/Type Name City, State, Zip Code
#12345 303-333-0000 303-333-0001
Attorney Registration Number Phone Number Fax Number (Optional)
llawyer@lawyer.com 09/11/2017
E-Mail Address: (Failure to provide an e-mail address may result Date
in delay in receipt of any procedural or final order)

E: Certificate of Mailing
I hereby certify that I mailed or delivered the original of the Response to Application for Hearing:
Office of Administrative Courts Office of Administrative Courts Office of Administrative Courts
1525 Sherman St., 4th Floor 1259 Lake Plaza Dr., Suite 230 222 South 6th Street, Suite 414
Denver, CO 80203 Colorado Springs, CO 80906 Grand Junction, CO 81501
VIA EMAIL TO: OAC-CSP@state.co.us
And copies to all parties at the addresses shown below: (A claimant must provide a copy to the employer and the insurer, or their attorney.)

Claimant/Respondent or their Representative: Antoine A. Attorney, Esq. VIA EMAIL TO: aattorney@counsel.com
Employer or their Representative: Emmy Employer, Employment P.C. VIA EMAIL TO: eemployer@employment.com

Other: Iris Insurer, Insurance Company VIA EMAIL TO: iinsurer@insurance.com

/s/ Amy M. Morris 09/11/17

Signature Date Mailed REV 12/07