Free Request to Enter Appearance of Counsel for Employer/Insurer - (WCC C26R, 9/2003) - Maryland


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State: Maryland
Category: Workers Compensation
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Word Count: 139 Words, 854 Characters
Page Size: Letter (8 1/2" x 11")
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http://www.wcc.state.md.us/PDF/PDF_Forms/eReqEntEmpIns.pdf

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WORKERS' COMPENSATION COMMISSION

REQUEST TO ENTER APPEARANCE OF COUNSEL FOR EMPLOYER/INSURER
This form is to be used only on behalf of an employer/insurer.

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

On behalf of:
Employer Only: Insurer Only: Employer/Insurer:

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

CERTIFICATION OF SERVICE
I hereby certify that on this day of , 20 , a copy of this Request to Enter Appearance of Counsel for Insurer/Employer was mailed to all parties or their attorneys.

Signature

CLICK HERE TO CLEAR THE FORM
WCC Form C26R (Rev. 08/28/03)

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