Free Req for Emer Hrg _H26R - Maryland

WORKERS' COMPENSATION COMMISSION

REQUEST FOR EMERGENCY HEARING
INSTRUCTIONS: This form is to be used by parties to a compensation claim to request an Emergency Hearing relating to a compensation claim previously filed with the Commission, where facts and circumstances warrant accelerated processing. Fill out this form as completely as possible and submit it to the Commission for appropriate action. This form is to be used only to request an Emergency Hearing and is to be submitted without a cover letter.

REQUEST TO THE COMMISSION
The undersigned party to this Workers' Compensation Claim hereby requests that an Emergency Hearing be scheduled on this case as soon as possible. The requesting party warrants that a copy of this request and its enclosed documentation have been sent to other parties to the action.

CLAIM IDENTIFICATION
CLAIM NUMBER: EMPLOYER: INSURER: CLAIMANT'S NAME:

JUSTIFICATION FOR EMERGENCY PROCESSING: Expedited processing of this case is requested for the following reason(s):
750 Character Limit

Documentation establishing the foregoing facts and circumstances is enclosed.

*THIS REQUEST MUST BE ACCOMPANIED BY WCC ISSUES FORM H24R*
REQUESTED BY:

____________________________
FULL NAME SIGNATURE

DATE

CLAIMANT
ADDRESS:
STREET

CLAIMANT'S ATTY

EMPLOYER/INSURER

EMP/INS ATTY

OTHER:
TELEPHONE

CITY

STATE

ZIP CODE

CLICK HERE TO CLEAR THE FORM
WCC H26R (Rev. 8/28/03)

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