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

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 17th St., Suite 400 Denver, CO 80202

By:

WC192 Rev 04/19 Page 2 of 4

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 aremaking to pursue your claim for workers’ compensation benefits and why you think your claimshould remain open. You must show good cause as to why your claim should not be closed. Thismust 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 ordeliver a response within thirty (30) days of the date of the Certificate of Mailing attached to thisOrder, your claim will be automatically closed. Your written response must be filed with theDirector, at the Division of Workers’ Compensation, 633 17th Street, Suite 400, Denver, CO 80202.

3) The closure of your claim will not affect ongoing benefits which have been admitted by theemployer, the insurer (such as medical benefits after maximum medical improvement), or whichhave 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 tothe 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

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 17th St., Suite 400 Denver, CO 80202

By:

WC192 Rev 04/19 Page 4 of 4

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 17th Street, Ste 400 Denver, CO 80202-3626

WC192 Rev 04/19