Fillable SETTLEMENT STATE OF COLORADO Division of Workers Compensation (Colorado DORA)

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SETTLEMENT STATE OF COLORADO Division of Workers Compensation (Colorado DORA)

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Colorado Department of Regulatory Agencies (DORA) is responsible for professional licensing and consumer protection in Colorado USA.

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STATE OF COLORADO
Division of Workers’ Compensation
Workers’ Compensation Number (s):
IN THE MATTER OF THE CLAIM OF
Claimant
vs
Employer,
SETTLEMENT
ORDER
and
Insurer,
Respondents.
The parties filed a settlement agreement, with the claimant’s notarized signature dated:
.
month day year
IT IS ORDERED: that the parties’ settlement agreement is approved.
IT IS FURTHER ORDERED: that payments to the claimant shall be made in accordance with the
settlement agreement.
Dated this day of , .
day month year
DIVISION OF WORKERS’ COMPENSATION
By
Director or Administrative Law Judge
WC73 Rev 02/19
Page 1 of 2
Clear Entire Form
CERTIFICATE OF SERVICE:
I hereby certify that on the day of 20 ,
a true and correct copy of the foregoing Settlement Order was served via email as follows:
By:
WC73 Rev 02/19
Page 2 of 2
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SETTLEMENT STATE OF COLORADO Division of Workers Compensation (Colorado DORA)

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Completed 27 January 2021

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