Free REQUEST TO ENTER APPEARANCE OF COUNSEL - Maryland


File Size: 91.3 kB
Pages: 1
File Format: PDF
State: Maryland
Category: Workers Compensation
Author: Webmaster
Word Count: 131 Words, 813 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.wcc.state.md.us/PDF/PDF_Forms/eReqEnter.pdf

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WORKERS' COMPENSATION COMMISSION

REQUEST TO ENTER APPEARANCE OF COUNSEL
This form may NOT be used on behalf of an employer or insurer.

WCC Claim Number: Claimant's Social Security No: Date of Accident: Claimant:

On Behalf of:
Claimant SIF UEF Healthcare Provider

ATTORNEY INFORMATION: (Complete in Adobe Reader, Print or Type Only) Name of Counsel: WCC Attorney Registration No: Street Address: City/State/Zip: Telephone:

I hereby certify that on this day of , 20 , a copy of this Request to Enter Appearance of Counsel was mailed to all parties and/or their attorneys.

___________________________________ Signature

CLICK HERE TO CLEAR THE FORM
WCC Form C24R (Rev. 0828//03)

10 East Baltimore Street Baltimore, Maryland 21202-1641 410-864-5100 Email: [email protected] Web: http://www.wcc.state.md.us