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.
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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