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.
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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