JAMES HOLMES 12C81522.

ieoptes exHtefi * loTEb page I ofg

SmartAdmin Claim

r!E!

lntsmet SmadFlle Admlnlstrative Applica{on

l5li:fos.l

,l*,1,:..:: .:Lt,* I
:n o,. oa. lEli,io:JlioTiii-l
,.lnsrrtur

NcEltED

Al

,s6a{g
",* l.,FAt,
,*a

:r.r.

sr.a,

i.Y r

:rth F|nJrd

ro

il4dId{6 v.rlfddon

rr:ir:Es:r pM

-l

le/ i 4,2C r 2 6

.
e.r

,*-.r,1!9 =-

*a"

PD6Ln: No

05:t6 Pi,r

4|-:

:rin rypr

[rriii----

---l

-l

L-..S1ros,l'trtrrdion....l

SmartFile Employer List

*)

!-oe,ndoy*,updrr"

our ar st.re ripoi-p,

L6r.k

l.ELk s.imire
lE grnD.!. ca tr210a
ac@urr sTci lilo

CO

NcrLi:re

ampioyer

d*irarc.l6.d. o.Mt

t
1l@1 E i?lt

FL4 A@.

AdId6"IC

. CO 10045

tto

f*eneoy*.ueoere

-i

Confirmation

http://spweb03/SmartAdmin/ClaimDetail.aspx?ResultlD=L196649&ClaimType=I

rD0t20t5

SmartAdmir Claim

Page 2

of8

Yo!,connm{m nlst ttn6aa

qIgLtrlE L vlfl . ,,tnL!r. 6F,

il.m; J.mi

chlDn(

lbr

Fur.hro,

ti.tm..

D.;.aBhn: trr3fiBu
3o6r.r a.edry

Nu6!..-

RdftLn.r.bt /r.u.r!y:

COIOIuETCI

6pt.r.r rn. 6 ti.rr? tlo

Ph.4.nnr0r.h.rd.yy@h.rr.rlad:

Ith. yo{. l.d

Its d.t

An ,.u flllna lhl.

Ar.y
g

snl

ruE y.!

Y.r, I dnt

l7l I n.y.

oarl!r2t,t2

Eold,a dn r hrE .Mmn.

.ur aa..6.d .1..? o

g.l I. to{.halh yfl,

lo

to

b,!. !,lb. ffirrorr

.igr

up ior

h."ployrnl

od .n ud.6r.nd

0!. .h@!

who

.p..t

E.![th

!.n.lllr,

b.

ttB

nd,

htum.tor

E I he Ed nd I {.d.6Lid h. .t { .t td.nrt
H.ryo!.lrr.iuprndc.lv.dW6,t.nC.6,.6tb.bin.r..lthtuy..n? rL
H.6,ou rlrd op r.r u..hplor[.rt !.rnt h6,rbq. r-ti.n C.t.Ed.. or tn C.n.rr. tn ln p..t i2hmit ? ito
wh rs ,.u{e.. rFn olr01zor t L tzntlllrr ..md h . n.Ndrttsr, rnC n6.a.d...1 .tuD.n .nrtorfidt h . !a.t (.1 crh! 6.n

Ar yq . i.mh.r

ol . Unl.n? No
Ele. olill,ioll, h.E F{ {Md hln.

tlrs

yo(

U.a.

mIt .r

Lr6?

rqt.d br.ny.nDLF $.4l,r. n.t nd..i.ltlllo.r n lt rr.lm. otDirtott? Y..

Yoshdlc.Lyahta.id.rmnt.qtld.ordlrxr..rttilhl.Gn.y.b.rdGt,D....y.urGt.h!.r*itry.en6t.h.q.rL.{d.[I
Lle.r.n n& ,.!r...rr.b.r L ilq
Nd.: tryn n s wit., li.E you rqi.d,'E mu EVERY l.b y@ n.!, .[n I y.u oriy s,tix, ,0 dnur.i Wb dr mn ..ry lcb h hy rt h. fi. Oku.t
ol C.l(hbn, Pu.io Fl.q .nd h. U,B \Itrgh l.hndr lr r@ m d h . hllgr 6dry 6r . U.S. @rlontdr dld !l. .t t *tt.. 0x hptoy.r E ri.d
Piu, .h*l

lh.

.lll.r

ycu

tR. wt.d

*'o ornla

1:

MARYTAND

E
E

RHoDE rslAND

E
E

ALAsx

AFEon^

El

lFMNsAs

g crtjFoi
I colonem^
I coNr,rEcTlcuT
g DEraw RE
e olcr cooMBtA
e FloRloA

E uonssore
E uEalsslPPr
E $le6ouir
A Mol{rAM
E NEEE 6tq
E NEvrD
E [Ev!, MTTPSHFE

TEMIEsSEE

rEr^B

B
E

vEirvorr

vtRcrNr^

C, GEoFo^

E!

NewJahsEY

nlfinI
IDho
I lrlNos
g lNouN

tEwME\tco

5
g

El

NEWYoRK

wYoMrNc

tf

noRrH

EI

NoFrH DAxor

oHrc

loREtc,|

low^

EI (^|s,rs

kEMnrcKY

Loursr

cH6rN

lourH o t(ora

urAH

IMic Er c
E) w 6milcroN
wEsr vlictNr
l^rscor,lstN

RotlNA

El on eroue
e} oREGox

EI TAflE

E}

PENIIEYLV NA

PUERTo

Rlco

Pl.!.m.ltro{.r.r8*|Eny.uo .dbrri!6ot/olr2olt
.l.. nro h1. NOI F*.d
O c uFoRNt
O co(oRAoo

solrrH cARounA

h .iy ol llx

1.l.. drnt

flrL

to

lztrzotii

&r ln.r dkl t..niE'

hup://spweb03/SmartAdmir/ClaimDetail.aspx?ResultlD=l196649&ClaimType=I

1t20t2015

SmartAdmin Claim

lha

Olrorl2oll

&n

Y.u

Page 3

h.r.

,td..t o.wm.nt

y.c h.J . Cnlhn hb tlrn rh.

|n.n .n. .1.r. b.tw.!. O1/Ol/2Ot

{6.1 Und ol c,.Jtr r. .lm

l,

t...

.ftr
6

Pldr. CltsljtE h' 116 htom

on

contt.{..

id

l2lltrlol

dg.!

lboll @btnhC

1.

tnctudt.s rh. Ut, po.ht

yd turl d@.. ns

tEn mlE th.n on.

you

e.nl

6.pt..i
ro

.bn c? ior u..rr9bym.t Wh.n ,o{

h.6 choun

,in.

PL... .ftr .n .prlm b.le Y.u a .lgn up hr . Cliondo d.t tr {. r6h"r" !.=1$ sn B. ,.6 t d.Et EC.. -d
hd nu.rr mn., yo! g.l d un.nplorn.nn6chln tht!?l/.}

. He rgs ktFf.md to ONE.I lh. !r.i.. und.r. C.'lbimd $t!.

. Fi. . d.1.. in oNE .l G. .1.r.! rd .nt ur. lltlt d.t . Eg.t

of 8

y*

olh.r C.tmdo MC6 to tClE or,

AgEm.nt

Fo,th.clrr.nrconL.tc...,ei30331&!000(D.nE.@t!.6t)w1-3oo3a&55t5{ourtd.o.nwr{.r!.8.).ttb.E.p."i.m,30.ntoa30

Tr'.

Mou.tr6 dm, Mondry

hrd.c lnp.IEd

0rB{h

Frid.y. llb

.rot

!l'.

o.

on fioo, 30131&901n (o..v..@rE

hoUrr.y.

.c.)

or 1.roo,l9+7r3o (outtla.

Dov.rmlD

e.).

N.m.CnaE.
H.r. yo{ u..a..y otn.r n.m *irh.n.6rl.y.r inc. olrOAOi l?

atdru.:

No

P.d, St

1690

'10

Clty: A@n

sr!l.:

CO(OR^Do

Z, Cod.:

c.!nv:
:11I

rl.l.

rh.l ildr

!0010
AEArrs

smnt di6.I .ddE. I uri.6bnd

oEl

ir

do

rhb.dd6.t

mi{,

lt

n.y hold !p

t rw o{f, !.Btit.

EmrllAddEsi:
Pl..!.

eiy.

!. yu HEi

.v.n

You

ilyulCl.ld

.ddnsr. vlb nE.Cly

3l9n up lbr ilyul Cl.lm.nl

on lh. hn prg.

(o!r

666mrd ye

wbrll.

uEl

l.l,

in

as E @d i.

e.i h rou.n ,iln y.c .bout ytur cl.in

y.u bok lo. your cr.in lnlom.iM) @e you tnilh y@r .i9nh9 up ror

h.nd.yD6!

ltb dplrh

Em l Addnr: d.lFdod(!holh.i.M

W.

iod . llE hri. nmb..hn.6

Prlc.ry T.h9n n.

'

6 6 sa.d

illnb.i

!.lor.n

DqurDrt. l,

c n.6 qu..tj.n.

.nou you d{6, tJ.t b.tng

.!t.

to

ct ,o!

outd hotd uF

pry[.t

ol

ar5t(a973rt6

riy priB.ry !.l.phon. b.lsngr l. . lri..d

1l!. qr.ao,l..

you

y!!

or

do nol

ldit

o.iiD..,

lGh lo

.rlE,

You say

1..v. .

fi.r!.!.

phsr !.locl,'ChG.

lor

not to

E. .l lhi! nurDu

hM,'

Nol

.nMtu! fin dor

mr rn d rn!.h..

http://spweb03/SmartAdmin/ClaimDetail.aspx?ResultID=1196649&ClaimType=I

yd

rirt

!.t

112012015

SmartAdmin Claim

Page 4

of 8

nhrdtlstl.ni Nol H.e-ic d !.!D

ld..tlf,.don: \iJhlL
D. yu hs I dhbl&r? Clr... llot t A^Mt
Elhnl.

i.n

Llviog End Worklng ln the UnitEd

R Lw,..Fr.lllo

hctudln! oruaplorfr.nl

n r..&

W.

StstB Legally

ll,.e o'.!. qoliL.nult,w

ltullt@.

y.c lo ..nd u.

F6.l

Vlr.
ol

dmcl

0vkB..d Enhc h n unt.n sEL. trgdly !.r@ roMrt.t.t! f

dtB yd .nm th.t F! e . U.3. dfz6;6 io kC.It. -

h..r.h. t

ttdtr.l

b.mr!

drL...hlr.

I.fid I.o. Unt.il alx.. cld:.n: Y..

1,.,.o.fi . co rff{/.Uon- 6rCOsut
Pr..-.nl!r rolr Drlu/r U4.r
nlnlc.r r.ur 3t i.ld.ntltlc.don
-Y.Eun.rrhrn.nl b.DltL

ln.t

ply y.o uEhplormrt

e lenb

ys

tO?

t ddl ed

b, to0r rh.

i.

lollmnt

h.wtr.lug l.hm no6 your t.n.tr p.r!.ot Y@ m.no6 5 helhd.ElhE..t.h t :.+ r.d.nl bd.tn ru,trb tu.t 1116 n6 yer
b.n fi!.lt/hl. ,@ D a lndryloyndl ,ou a. ch..p. hrt ffty d@. Y.u {lI b. .!1. b do $.t on th. !fi6. or on yl.t| Ct tn.nt rryut CLrMI ot n 24,
You.n

.n[6..4.ioyoqcLlm.Yo!sl@t.lrtlirc.taon$IryoEchlh.na!.t.tl*diodnyqrErimrrbout,ori'd.i,(Youreift
.nd ol lnl. .rpltrlq lii .rrldn tuE .6.r! lrr|g MyOl Cr.loot )
You

e rtl 4rtd@

$6ur

lld6l rDrt b

u 3. rn..d.r E.v.nm

!!IadEt!l!18!!g!! [F!rv.h color.&.llytu !wh mrir

Pl.@ .i.h vdl.t ro! uir ur l. t h. qit
Tu rlthholdlna: Boh F.d.rd ..d St i.

s@r..

Y@

trrr., y@

c.

tonp.g.dln.

!a. Bk qlatonr .b@l .t.t. t s b ll!. c.t db

ttnd out rt!. to rtk rLt ind. r.r slaldod ltlm ti. co6m.nt !r.E

i.rt

f.d6.t io!t .cd6dca*

PI.eI .. hu6odnl.lo
U.6l O.ap.{.rd Tl{.:

tsbclG.hrom.ton

b..l frr y@rrdorF* qp.n

n{

O6rrdi.6

Ur.. Ptl,rlsL .dr Sodi 5<Ln6

Cnoo.. . lrort Fo.!. C.nt r to R.gLbr to. Wo.L

lfJb

dnnol pry y@

ilob: Ye d.

6.1

r.firlotri.nt !.6n! !rn...

irv.

lo

G!r.l.r

lcr

Ed

l, yo!

,ou

.o

nalr.r ro.6rt

eor,t !..1 lo

s*

6. y.6 .nployr (lEEr(.!rId)

or

c.i yoq

srL t Fulh . 6h.

hi.ha

h.r

AlCOLORAOO.ridulrmucn.k.rlorr5l.b@r.d.p..6.LYoursrttor@t.edr.g.thdrumb.i
Cnoo... Ffiio@

c..l!rb.I

h clo{ b

y4 Ys.o

Pl..!. !.lct yd. col.otlaDo ro.tforc.

CA

nol oCld.rhC

...t i &dr

lorf .,.!.6 in Eh.o.i'E.6*roo 6nld

c.unr, v\h r.@ .ni gqJ.... c.nt

r.353a

P.od. 5t sr.

llt,Am

ploytr lnlom.uon

Llu rbB! a.dr 01,r..odol.E lb[$m y@ NEil.d h CA i!6 0tro1E0t I b 12/31/2oti. B.!ir *irh Ur. CA.iEbr.r t xar6 r.u s*.d mn
.onlt llta h.s s,t!d,q 6.hFloy..r@ !16 mo, E iid ln kturird h.pp.dd lh.l.d {myo! .t!fp.dF Lg ior 6n.np6r.r
Pl..n

C.mDay il.m: A.d.t Ad.ntttc

.
DoItraC{.In .!A..rtn.rr.6.:
T. p^C.r}.y
YourJ.rD

iLr. .t
Y.!r

EnrPt

Y.ur

TE.:

C6. ngOpGtd

3uF.nl.oi A&aPl.kt.

F/.c..r..t Nuii.i

atg2raltoSa

ComD.ny5ludlhs AddE.r

nr.lAddr..:
St-.rAdd[..2:

A.Etlt

tna

2275 Rto

ntio

Wty Srlt.1aO

http://spweb03iSmartAdmin/ClaimDetail.aspx?ResultlD=1196649&ClaimType=I

t/20t2015

SmartAdmin Claim

Page 5 of 8

Ett:
ztt

r,hd ,.u ..tu.I, s*.d

l.

Phy.l..l

llFoArtll,A

c.d. etot

(phy.Ic.l lod{on)

lttt tAdd...:

dli.rn( lEd $. .npl.r.L h.llha ..ldr..? Y.r

MriEt

PBdsl $r.t^ddn.r2: 2550Plo,EAr !l.lacasii,r

thy.td CtI

Vt.t

Pnydd gr.b.
CAUFORM

PnFlar aP

c.n..

@06t

FIE{D.rY!(wbri.d: loo&2olo

L.lo.,

Y.c

tYo*.d:

Ol/20r2ol

Hd .Mh th..hploro rd.t Y.u?

i1.00

t.n Holr
Itr Mr!.r ot noE ys 6rt.di a0
ft, dld ,a .lcp wq*ht 0rn? odl
rl.ryou *dt d L...y orh.r CA .npl6r.r.l...

Ol/olndr?
FL.s |.ll 6 mE .!oul rtry ,@ $4 A.obk ad.n{nc

&

Nor.:Yo{anEtty9.llulhe160.h.6d6in..diadlry@ediotk.ur'rdhrdrnddfreF,qnlyp.Inh.bo1br!53o]31]rora6ndl
nioPo &r aoo. o.mr. co!@ot- Aiy n Fc snd o p.D.tu!il(, fr.r. @tqr F, y4, nl nm.6d.r b.n u. hrl6u dleig olrlur$.Id r@nry

tufrDr..h.aAr,'.od.lll'l!raclatt.n.EslLlycutlrh*h.6lonnd0*t
Old Fu dw n.ild Lr.n y.! qum Y
iLE..nd CiL ot poon ,.{ tolrt Ad.6

Pt

ld.

lldmchnod..dlayouel!.t, honth
,l.r lo qr rh., ,os 5nt lo srr on yd.l.d.Ly? Yc
cr* on $. XAll llen rlry you t{lt To ov. cr ol1.
Old ycu

wh.r drd r.!.to r. trr ro

ne.

l rh.t

dld

y4

g.thire eBtlr.
PL.n

ltr

ne16 ln. thbl.n dd

l.r qutilnl?

..h6ol h .n.lh.r

rl[ u nd h6tui..

on

*lt

Glv.

*-, t!(.l.bt

6 d.blL,

la

ir. w not. robr.n

.PPdldl, .o..,

rou dn nol

r eEs jabAro$.riiit

!lr. . l{.n, pLe rrlL li.l

.Ll.

you qu[

,E[.k S.lsilre

tt. m6!e roo0 d.r!Ga.E lnd.,h bd lfr n..dloslE6mnhr.'r &nlh.^ t& on tr.ln llr. bo( Lr 0 t 3@31t90r.dml
hroP,o Eor,oo 0.M. co ao20l. Ar,ld FU $d ur p.p.M*. fi.t &6 ytu pulroarnrl M..na rl L.rl0r. L.l lbr dllll.rrq.odd R y
Mt 16'lh at th..ni .r tl{. ?F orid, s {lr Llrrtu.!trL lh.6 i6 sd 0 nlr
&{.. Y.c6n.r
Dl'l y.u

lll@

nos.. ot tLllh.r

rtn yM.c.e,tt. nov.d rc tL. nrlob rxno$ iot trldrl? No

h.rt 60.. y@r mln .,.ro{rt d{ry.rl{on Er .i.na.d? Io
Dll,.u br r. r{ t. od l|r. n.hbd.l,@. lno.ahh n Iy iho {.lI o.rodlr.r, tlo
LI udrn.dln.tIn.,h.s io !h. y.!..r.b il P.ovltc h. !l.q6 d{tlit otnv rudrl. I.nl, mhD.i
(,ld y.u t r to aoE h.c.B. oI y.!. t{llh r $. h-th cl your tDo!..6r d.F.nd.nt.Hldl ilo
old y.u h.E .trolh( lt.s l.r q{llin! to ms? Y.!
l{ty dlC you qdl lo rM? T. r@u. !nd!.t. rtrd..ln rh. r. td!@..
ro{ lolt lo
OldFc q'lit
Dld

ap

ll,tl.t o..cn 4d y.u alv.

IoFnu.
Pt

nrn.

li.

.aploFr t4 q!ltd.g? Gl6 s. a.Llll. l' ror 4d n.l tlE .

r..d, ,L.c vll. O.l

,uf,.. in,r,L !d.nc...

.&.nsrrh.lbadh! qG.tlotu.b@l R6Mm p.y mltlmrGt t sd.r l.

n6

h6

lFlm.{on lh.t Fu
.L: Yo! oml tp.
lhr. lO00 .h.Edc ln.rdr bor ll ,ou n..d lo !iv. !t
trd.l
&E ro,{lyo!r|ld
r i. PO &r aoq D..Er. CO !ll20l, A^y UD y6 r..d {r p+.ierh
nuflh d dr.d Ar *E dd ol Ui..D!dl6tio'\ F wlll t l yo{.c.h lh.n &nd hln!!,
oL

r.! 'ul6.

dll ,or

nc.l[,

W.a.. h ll.r .l n.!..? lPL.n

Old

yo!

ffL
t

do 6.1

[618. ,ll ,.c nc.lE, .r.n

o.nr -l.ndcn p.rmiB? EllEIE

P.n.lon,
la

yo!

i.{

yo{ Ec.lvLa .ny d rli.

you

srlad

.nd

EE

a.ld

t ro

y.!r

lEa

.hd4 I{.

,!..lvha .ry ol lh. llllgilng ,.yro6 lDm A@Ll s.l..tlL:

!!L tL

r.dnn.i! oiloll dld.ltc0on.?

nct

o tF h fi. ld. i& I b !0$31}901a o. mar

htc lE l..l td dhtu oryqatd.l i..{tly

l-ltfllng ,ryn..L lLo a.di.L 3.lr{llc:

-9.n p.yn.nL te ftou.

y.u

.lE

No

o..l[d, llt .E r4..tlna l.

D.

,.lil

..,

ol

lh. .b6r ,.yn.nL

you

tul rg.d

ln. ,.rn..rt L

itlvl.td rh.r

htto://soweb03/SmartAdmin/ClaimDetail.aspx?ResultlD=1 196649&ClaimType=I

nol{d.

t/20120t5

SmartAdmin Claim

Page 6 of 8

Col6r.do EDploy.r Inlormrtlon

PLq ldl ut.!ou.rdr olaE .oFloy@ L."n6r@m

@nlr. lt |ou h.r F,t.d i.r s .trp1.y., ho6 thln ffi..

cd h C.t odo .L.01r0!20t t. t !h,tr,l rr Cdond..trpl! .lb, rtM,e,rt.d

@ 6.d to rr@ rn.l h+p.h.d 6. r.rl t&n. y@ doi?.d y;ri! tu n.l .mitor..

C.rp.nyN.m: (rriretty oti:otod&

Your Job

Tttl.:

m.l

O.nEr

Gr.du.t. Strd.nl

t.m olYou.sor.tuLe A.{t Rb6

YorEnptoFa.

c.nu.tNra!.r

Color.do Elrploy.r il.mns

3o3?2a4517

A.dr...

!t!.1addr..:

t3o0l E rTthPko

cllta Au@
3t l.:

cotoMDo

zlpC.d.: lo0,l5
rh.. you .ctolly Erl.d lpny.b.l loq{o.j .l(l.Dnt n!6 th. mtroy./.
llry.lc.l !h.t Addo..: Rc1.N, M5 a3t 5. in 7107

l.

mllrne

.ddd.: Y.t

thyi.rt srrd AddM 2: t2!@e 1ahA6

phy.trt Clq4 Aum
Phr.lql $.r.:

coloM@

Plry.lalzPc.d.:,OO/ts
You

woa.d:

06/ll/2oi1

O., Yor

Wb*.d:

0lL/13/2012

Fr.r o.,

f..r
fi

enu.hln..6rlryar.kltoo:
P..

lh.

rurhr.th.Er.!sA.d:

21i637
M@rr
40

,.c .l!9 wE*lnt ltxE? qll

H.f t u r.rLd t . .n, otlEr.6rlot.r lr c.l.Edo .ln.. olrolrloi l? tL
Plrr. L{ c. mr .bal *iy yq quil Untdlt o, CoLE/o O.nv.i
Wtry dld

.r.|

..el ryp. d. lnrn lom dlad.6 h ..dr bor It yq n..d L ar. 6 l'6 k'loi 6an rh- t& qn ryp. b h. td, Lr lr ro 1&31a9014 o, m.jl
Bd aoo. o.lG, CO lo2o1. Any Um you e.d 6 t+.M( frk! .d rtu rlr y.d ll, nfr. sd.r 5!i 0E lqt tai ddB., y6.od.l .@nv
m.6, ar rhr.rd.rlhl. +r.alio46 e l.l y@.!Eln irr.6 t 3.d lnin!..

Y.u

tbP.o

n!

Ds

Drd

yd dE..do

i.mr.d

tlrL

l.td

y.u q!rr? Y.r

olr6onro!i.rr*

llor tuch tudc. dd y.{

Grc ctulr

PEr.$rsur6n\[t rr!{,Eun

glv.t 2 r/v..b

Dld,o( p,., to lut in.n F! sd t rlrt.D yqr l..t d.yt Y.r

Ohr on l,l. MA!{ n..on Fn, yoc q!n: 06 io *ni.e @.dto.t srdr G p.r, ho(.. dut
Wfirl dld roc

d.l. l,,roE.olv.th. rEU.nmd l..p y.uj.!,

BsCht

r.

.uFvl!L.

cmld^C (M UE.tudlnl mnt t h..[h

qlr.tr.tordldyorgl[a.rqi/ltdn!?Gh.u..Li.!L,lirouttin.telE.tu&n.pk..,rtt tfi.t
PuEU.,

6lh.rLi.rot

.nd

l.d o,p..rbnf.r

Nor.r Y@ q.rEl Vp! mF lh.n lO0O d.ft1.6

Do ItF! n{diod6s
hlm.0o. c.n yor
I io P,O Eq a@. o..wr, CO lolo't. A..y litu y.u md E
6.L eE yo rrr rolr
d.nd.t
.@bi 6lh6. Ar ln.
lhlt lpd-lls, E sill t l y.! .l.*r rnd b t.ri !t rls

h...i

-d.f

Erpr.h ln.

c..cl0c.l.l ln.l mr,. y.(

E.lor y.! quq

dld you

Wll.r dld y.u do

ro rry

{.I oyor.

ln

q!lr. Pl

... dy. ..

6.,ry d.n|r.

.dho.Iy lht ,@ dd n.t l&

b Drt 6lna. oso All.trpEd

m.

F!.M&

O!.

tui

h rn! bo!,lu I b 30!-31+9o1a dE.!

lh. L3t loddtCiLorytur ro.id !@ity

ryp.

b.n

lrcl.ri{.Gt di]IG too &d.t, dmmr e.cr.dv.t

- !o! 6r: !n
tdn{lE Derdr .!!E..i.r.

s.tl4

con IO6n.? No

drala d.mu.r b .a moc .o.t tV ud

b. no6 dor.r.. H.wsr, Mr un.bh to dE.Ct
ro

rht/Er.md o.tundhy.

http://spweb03/SmartAdmin/ClaimDetail.aspx?ResultlD=1 196649&ClaimTyprl

1/201201s

SmartAdmin Claim

Page 7 of 8

l. l ,t@n tlt.t n { .&l.ln. sn, you qs(: BdG. ,ou nor Do th. e.th! @n tds
'td
lrfi.t ... lId,!u llEth.@pt r.rtor a{tt!.!? Gt{ 6 d.r.lt.,I y.u dtd..t glv. r {nrtto..r
P6liC othr hl6.t' .rd Lct .l ledon it

O&r c. rh.

...

Pt

!.

slv.

. th.t

mo.r lntorm.tlon on U. sn!.G&ctory worung condtator! .t Untv.Etry o, Cobrado O.nv!r.

oh: Yo! 4n r yp. E.E tha to00 d.nc.n h..clr lor frou.ad ro ds ur a@ h,ortrrdo. lnr yo4r a tp. in 0r bor, tq It aO]i,r!.,i,ra dm.n
Ir!PO Bd a(tr. Og[r. CO l@Ot. AryXm FUs,n u p.FMn. mt. s y@ rl/l Fu ftn nie.id.t h.i'$.
hll t ur iigL.ay@ r.d.t l.qriv
r4b.r 0r lE6 Ar 0l. .nd ofihlr .!rlk . F eit l![ you .!.h B,rE b ..d, t*ra!

dor dd ln. Friilna c.ndhlon. rtrt ,06 h.rnn, rr.ry. .8t .r n.dtt? t
a{o tllk io hdl|h, nnly. d mnh

.rlit d? 6h6

Hw l..g h.d rh.n srLlnl .onat&..

b.cnnh!

$.n r. i6 d.t

afr....tdlhr r&*

9.....nMr

tEdUrrr.dr,

hloriie q{.i16..rtlurlgMngp.y66t

,.{r n..fin. -i.ty, 4 m[t.,

pt

.x

..y .o.

!i !fftu.t. k,t

wbn tt. ddlllmr t !. rn.lo. dn..6r*.8 xn. dd {r.

Dld lhl. ,ob u. y.or ,..r .rp.rLra .nd tatnt.o? Y..
rh.

to

tbr tJlt.

C.t Edo

srtoy.a y.t

t.nG,

N.i.rYoudrltt.BDurnl0oo.nEc!6i..rdrb@llydn{dt.Cv.clmhlorrEtbnthsy@sry!.in[EDor,|.lIt.3c!3ta-Nota6m.[
lr r. P o Ed ,rm,-O.n$. co !0201 rr.rrxtu y.u ud !. r.p.lwl( tuk. m ya put
t.ur rrr nffi. .;d .t t..i 0!. Elr r.u i,C ! or yow !.d.t !@dt
Non, 6 ,rd.. Al O. .nd ol rhlr .pprBbr. s BiU r.ll yd !C.rn !i@ b qd 8ltn$.
Dlil

tou

edr,,l[ y.! tudn,

cr

m y.! ilttna m,

w.e.. h ll.u .l nodo? lPlor rL ..t nrat p.yh.nr.

Dld

y.c

ralr.

dll ,oo

.alr, or.d

or aott

lor

tu tCtcl|na p.y

hdE y.u

srt

yo! r..lrlnC .n, d ln. ,oiorhg

otlEr..r..rbo Fyn na?E&Eldtsl

Pr...r. E{.mnt

ct

nr.

..d

tdi t nlt.dt.tcohad. D.Mi

ls

yh.nts

,.td

tt![

6..r y!!r t..! .n..{

Untvortty ot Cot.ndo

Etv.d

{ot r.t

D.nrE

No

d.trtlItond

tlo

It y.u h.w ..1 n..lv..l, bol .o .rP..Ing l. t. p.,d .ny ot ih. rb.s Fttmnr. !E! fiu.t np6n tlr p.yh..r b !h.
ll.n .mrloFr i.d qll.d ycu lc .t.n. ll F!. x.!ld y.u lIE h{. tlh lo d.n s* rtgtt rur? Yq

dtet l.n

,i.n Dotrd.

Wa.ningl
Yo!

.E r.l firillh.d nrr!

@l r@r

iJlepkyn.nt .r!Xoi@ ,.! 'lllh t. ilot 0r t .t p.F !!t vd dv. yo. . @fim .. Dtrlbrrh.n ,.u i.r i ah.d,

Dor't Forget:
Y.u qn oqrrt ,.yn.nl l!. 0l. nEl two m.tt .rrar.l.lh on 0,D1aOr2, You m nqu{ p.y6r{ 6 CUEU^. onh. or cuEth. yd Eqld
cUBUr & h. ., CUBL.. .rry tE El. co to !4r&EsbGlgrslEdlslsl .rn dd on CUBUB o,$., o. ct 3dtlu!2roo llri.v.Mar. t ,.rm.t
ir ,

I'AI&55G240O(odtld.O!M.@iE6.)R.qn3ilnop.yrmrl.y.urutotLrhc!.l]idy.u.dtE.du(nrroyfr.irb.n.iLy@q.rq-d,m tu
o7lor/20r2, YouBln on6b!.rn.n lo 6qu..r p.yndt.rry ts 6k!.nr [r.L rn. d.t.. drau.n p.t .nte on uyur'o*isi vu
hrnb@t rlI L! rou h i. ie. !p h.lryul CLhBlt

t'.tntrn d
You

mutl hok

to.6* li.w, wl

th.t

F! E+.n

. a!dd, tdF,i.l w.6n$i4.doli,o.ccm.

p.ym.t. ,In mn hpctunt

itllr

omfitd.E

nu DliJ.Ed t h6,youmnl' irr.r.sj(

.rc.t.rdd.nnr.drl...,!l.d!ycuroll.dlorcr($hled6.hrrdom.li.n(fin.ll.b.ttdr.dlY@6!tdb.Bt.l.l..ydm.toFE.,!q.
n@d ol rs Flt -.Eh
EEn

yfl

. Ars CUAUn. orli@.r ol, CUBLt!. ery iN s.t!.

. i.ron .rultly.nynoBrou srlld ed lMry F!.rm.d

drhg...,h

@l

yoo

Fqu.tl h.mtr r.ym.r!.

Not

E!.6ha

rdrtEf

.tri

.oh$

@td

Oth.r Pey Remlndot

Yoo !t i.d t'.l,ou c.ur9ord b Golv!. pryMl $.t b rctsr.. (i-.rfirpt tE oi,.y d .etuc. p.y) fm.n. oayoq6l,i6yo.Iht @Fi6y..
nandp.iay.uhLmE,F!Y.uFUrlEron$.1p.ymnrto6ln6youdlv.ltl(yddomtt.ti!..yo/nEt$h.v.iop.y!tt.itum,r.r.id,
,

pdd ,ou. You rrdn

&o h. tt p., p.dhL. c.0

rh.

cld.mr corrd c.d.r *h6

y.q ,!61v. tht

nrn.r.

Paymont Method!

u P.!tm L4. b.ndr prrmnts .ii!, .n ! \ris.o d.!I or! frmd

.n.dtr! ff nnno. -ful o,,our ctok .

lo

.r lh. c.tmd. arr.dt

p.yffrx Grn c.rn d

b,

dt*t

d.porr hb

Colorado Autom.ted Payment Card

Th. C.lddo o.9.nmer ol L.bd rd E Dtlym.nt (CDLE) B*.t th. CAP Crd thEuoh IE .$r{ Cn
Bmr (C}[!.). m ry.,, nk
d.irn. Wt rh o.
{br ltLrC,oul L, d.|'I ,ou fi0 r.dt. h rh. 6.! ,w CAP C.rn &d .d!{mntl.romt}on k! . d.tr. wn[. ..vdop.liDo Cn j., Cr.fu.y nrd a tu C,rp

C.d lnlsn

lio(l

r.r

!.!, nc.hc

Olrlct Oeposit
Th. ul

pEgtu .uLm.rlqfiy d.porkt 6u.llE

d*- F.yn. a.bcLr

nLryour tod.r

lo

yM clP c.rd u.l..r y.u nqsn dhc d.r4lt To ..t.ct r,tFc d.9o!t lo L !4t&r!!tEthllE&!Io .nd
MD.r ed lrt t &id aiiin!6on.r td;nrii..{6 &r'6((pNj ro bi m,t;;I;-*r.ld,tc d.r.a s

'@ir4,

http://spweb03/SmartAdmin/ClaimDetail.aspx?ResultlD=1 196649&ClaimType=I

u2012015

SmartAdmin Claim

Page 8 of 8

ydF.r.ddr.yrn.rnllrE.lYumlt..rth.b.nt|r.d,botErnjn!Mbr.bd.i.dhg
Fm 6. P.rh.nl Sd*{q !!r.t ,.!q
i'i I hm md .id

diE i d.r.rn .nd

0!

O\P C.r!

,our

lEt

n@t r b.r6ena6in!

mrt pryffnt o.thod .t .ry

yud.t

. ot

tt*

bdcrrd $. .to6 {.nh.nra

I.dfly m.t tI n'.ltrl|rtftd

n lrtl

,a n y 6md. h.t .6

*i.!. -@nt

!r.,ou

lt

hd lt @di&E lr.d. Th.c.o

c6 ify ttut tor.ry

tl,.nd @dct

ary Fmn lno lr.r

!.16 Mr.,.id

um p...1{.r,

@ird uMdorfrdt
uD,o

Dd ,ldldlltcdnin

D6dR. dr.lo tslr.

l

!i.t rmttat

p6.@tiot\ td amtdtrg itu.t

ttur

t dhdd..

ureet I chlm benerlE I must b:

colrydo o.rrrn.nt ol L.!o. .nd Fitolorrn.d to d..x n, @dr nd lniorh.lt n t. yd bt* b u.r
rt $ 0r C.l.ndo D.r.rhot ol Llld.nd Eipl.yrd xd il! .nploy6t nlm .f l.bav ior Cndlg r!.h
I..dlyih.t Y6,I6 L C9tr up In.. drn) Lr u.rl,loyrunl.
I .dndi:. ltf,
CAP oro. I

dn !d . d.th qd (.le .rt- nl.

htonidon rbod m to ,q hnt"

[&d(.lj I rElt rpeqgX.!,

c.o1,h6:ol I s!c.

oa

c.hdo

Al nshr.

http://spwebo3/SmartAdmir/ClaimDetail.aspx?ResultlD:l

R.@.d vrioortrtBai,

196649&ClaimType=I

1/2012015