Free Request for Modification - Maryland

WORKERS' COMPENSATION COMMISSION

REQUEST FOR MODIFICATION
INSTRUCTIONS: This form is to be used by parties to a compensation claim only to request that an Order be reconsidered, reopened or modified pursuant to LE §9-736. Fill out this form completely and submit to the Commission without a cover letter. This form must be accompanied by Issues (WCC Form H24R). CLAIM NUMBER: EMPLOYER: INSURER: The undersigned party to this Workers' Compensation Claim hereby requests modification of the Order dated and as justification states: The claimant is entitled to additional temporary total benefits. The claimant's permanent disability has increased. The claimant's permanent disability has decreased. Other CLAIMANT:

REQUESTED BY:
FULL NAME STREET ADDRESS CITY STATE ZIP CODE

CLAIMANT

CLAIMANT'S ATTORNEY

EMPLOYER/INSURER OTHER

EMPLOYER/INSURER'S ATTORNEY

A copy of this form with supporting documentation, including Issues (H24R), has been sent to the other parties/attorneys to this action.

____________________________________
SIGNATURE
WCC H30R (Rev July 2005)

DATE

PHONE NUMBER

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