Free MD WCC ISSUES FORM - Maryland

WORKERS' COMPENSATION COMMISSION
10 East Baltimore Street BALTIMORE, MARYLAND 21202-1641 ISSUES Claim No.
Claimant's Name & Address Atty. for the Claimant Name & Address

DATE:

Employer's Name & Address

Insurer's Name & Address

Atty. for the Insurer Name & Address

The following Issues are hereby raised by the: Commission Claimant Insurer Claimant's Atty. Insurer's Atty. Employer Non Insurer Employer's Atty. Non Insurer's Atty. 1 Did the employee sustain an injury causally related to an accident which arose out of and in the course of employment? 2 Is the disability of the employee (TT/TP/PT/PP) causally related to the accidental injury? 3 Did the employee sustain a compensable hernia within the meaning of the Workers' Compensation Act? 4 ) Did the employee sustain an occupational disease? 5 Average weekly wage. 6 Limitations. 7 Jurisdiction. 8 Statutory employment. 9 Medical expenses (creditors and/or amount). 10 Vocational rehabilitation. 11 Attorney fees/costs. 12 ) Penalties. 13 Temporary total disability from to inclusive. 14 Nature and extent of permanent disability to the following part or parts of the body: 15 16 17 Other (Specify): Authorization for medical treatment. ) Temporary total from

to present and continuing.

To resolve the above issue(s), the estimated time required for hearing will be . The number of witnesses to be presented is (if none, so state). I certify that a copy of the above issues have been served on all parties listed above by mailing a copy of this form to the addresses shown above, this day of ____________________________________ Signature of Person Raising Issues
WCC Form H24R (Rev. January 2000)

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