Fillable STATE OF COLORADO DIVISION OF WORKERS COMPENSATION MOTION (Colorado DORA)

Fill Online, Printable, Fillable, Blank STATE OF COLORADO DIVISION OF WORKERS COMPENSATION MOTION (Colorado DORA) Form

Use Fill to complete blank online COLORADO DORA pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

STATE OF COLORADO DIVISION OF WORKERS COMPENSATION MOTION (Colorado DORA)

On average this form takes 16 minutes to complete

The STATE OF COLORADO DIVISION OF WORKERS COMPENSATION MOTION (Colorado DORA) form is 5 pages long and contains:

  • 0 signatures
  • 9 check-boxes
  • 60 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your DORA forms online.

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

BROWSE COLORADO DORA FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
STATE OF COLORADO
DIVISION OF WORKERS’ COMPENSATION
W.C. No(s):
Carrier No(s):
MOTION TO CLOSE CLAIM FOR FAILURE TO PROSECUTE
IN THE MATTER OF THE WORKERS’ COMPENSATION CLAIM(S):
, Claimant,
v.
, Employer,
and
, Carrier/Self-Insured
, Insurer/Respondents.
The Respondent(s), pursuant to Rule 7-1(C) of the Workers’ Compensation Rules of Procedure, move that
the Director close this claim on the ground that there has been no activity in furtherance of prosecution of
this claim in the past six months.
Specific facts supporting closure are:
WHEREFORE, Respondent(s) move that this claim be closed for failure to prosecute.
Dated:
Respectfully submitted,
By:
(Name)
(Address and telephone number)
WC192 Rev 04/19
Page 1 of 4
Clear This Page
Clear Entire Form
W.C. #:
RE:
CERTIFICATE OF MAILING:
I hereby certify that on this day of , , a true and correct copy
of the foregoing MOTION TO CLOSE CLAIM FOR FAILURE TO PROSECUTE, was placed in the
U.S. mail, postage prepaid and properly addressed to:
Claimant Name:
Address:
City / State / Zip:
Claimant’s Attorney:
Address:
City / State / Zip:
Carrier or Self-Insured:
Address:
City / State / Zip:
Carrier’s Attorney:
Address:
City / State / Zip:
Other (please specify):
Original: Division of Workers’ Compensation
633 17
th
St., Suite 400
Denver, CO 80202
By:
WC192 Rev 04/19
Page 2 of 4
Clear This Page
STATE OF COLORADO
DIVISION OF WORKERS’ COMPENSATION
W.C. No(s):
Carrier No(s):
ORDER TO SHOW CAUSE
IN THE MATTER OF THE WORKERS’ COMPENSATION CLAIM(S):
, Claimant,
v.
, Employer,
and
, Carrier/Self-Insured
, Insurer/Respondents.
Notice to Claimant:
The Division of Workers’ Compensation has received a request from your employer or workers’
compensation insurance carrier that your case be
closed since there has been no activity on your claim for
the last six months.
1) You must tell the Division of Workers’ Compensation what recent effort you have made or are
making to pursue your claim for workers’ compensation benefits and why you think your claim
should remain open. You must show good cause as to why your claim should not be closed. This
must be done in writing, and you must send a copy to the employer and insurance carrier.
2) If you did not already send a response to the request to close your claim, or if you do not mail or
deliver a response within thirty (30) days of the date of the Certificate of Mailing attached to this
Order, your claim will be automatically closed. Your written response must be filed with the
Director, at the Division of Workers’ Compensation, 633 17
th
Street, Suite 400, Denver, CO 80202.
3) The closure of your claim will not affect ongoing benefits which have been admitted by the
employer, the insurer (such as medical benefits after maximum medical improvement), or which
have been ordered by an Administrative Law Judge.
4) If your case is closed after 30 days, you have the right to petition to reopen your claim, subject to
the provisions of § 8-43-303 C.R.S.
IT IS, THEREFORE, ORDERED: That if a response has not already been submitted or is not mailed or
delivered to the Division within thirty (30) days showing good cause why this claim should remain open, it
will be automatically closed.
Dated:
DIVISION OF WORKERS’ COMPENSATION
BY OR FOR THE DIRECTOR
WC192 Rev 04/19
Page 3 of 4
Clear This Page
W.C. #:
RE:
CERTIFICATE OF MAILING:
I hereby certify that on this day of , , a true and correct copy of
the foregoing ORDER TO SHOW CAUSE, was placed in the U.S. mail, postage prepaid and properly
addressed to:
Claimant Name:
Address:
City / State / Zip:
Claimant’s Attorney:
Address:
City / State / Zip:
Carrier or Self-Insured:
Address:
City / State / Zip:
Carrier’s Attorney:
Address:
City / State / Zip:
Other (please specify):
Original: Division of Workers’ Compensation
633 17
th
St., Suite 400
Denver, CO 80202
By:
WC192 Rev 04/19
Page 4 of 4
Clear This Page
COLORADO DEPARTMENT OF LABOR AND EMPLOYMENT
DIVISION OF WORKERS' COMPENSATION
Motion to Close for Failure to Prosecute
and Order to Show Cause
(Form WC192)
There are no open indemnity benefits.
No activity in furtherance of prosecution of this claim by
either party in the past 6 months.
Both the Colorado WC# and the carrier claim number are
on all pages of the documents.
The Name, Employer, and Carrier/TPA information are
on the documents.
List specific facts
supporting closure on the Motion to Close.
First page of
the Motion to Close is signed & dated as well as the Certificate of Mailing.
The Order to Show Cause Certificate of mailing is NOT signed or dated.
A copy of the Motion is sent to all parties including represented claimants.
Include addressed & postage paid envelopes for mailing the Order to Show Cause to all
parties including represented claimants.
The complete packet and envelopes should be submitted via regular mail only to:
Division of Workers’ Compensation
Attn: Claims Unit
633 17
th
Street, Ste 400
Denver, CO 80202-3626
WC192 Rev 04/19
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

STATE OF COLORADO DIVISION OF WORKERS COMPENSATION MOTION (Colorado DORA)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 27 January 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document