Free STATE OF COLORADO - Colorado

STATE OF COLORADO
OFFICEthOF ADMINISTRATIVE COURTS
633 17 Street, Suite 1300, Denver, CO 80202 Fax: (303) 866-5909 1259 Lake Plaza Drive, Suite 230, Colo. Springs, CO 80906 Fax: (719) 576-5978 th 222 S. 6 Street, Suite 414, Grand Jct., CO 81501 Fax: (970) 248-7341

Claimant, COURT USE ONLY vs. Employer, and Respondent. PETITION TO REVIEW (RULE 26 OACRP) WC NUMBER:

TO THE OFFICE OF ADMINISTRATIVE COURTS AND JUDGE _________________ : The ( claimant/ employer/ insurance carrier) petitions for review of the order of Judge _______________________ issued on _________________ (mo/day/yr). No transcript is requested. Petitioner objects to the Findings of Fact, Conclusions of Law, and Order of the Judge on the following ground(s):
(Set forth in detail the particular alleged errors and your objections to the order. You may attach additional pages):

CERTIFICATE OF SERVICE I hereby certify that a copy of this document has been mailed to the ALJ and to the following parties, at the addresses shown and on the date below:

ALJ: Office of Administrative Courts

Opposing Party or Attorney:

Mailed on the ______ day of ____________________, 20____.

Signature of Petitioner or Attorney

Petitioner's Name and Address (Printed)

Revised 01/13/09