WORKERS' COMPENSATION COMMISSION
REQUEST TO STRIKE APPEARANCE OF COUNSEL
WCC Claim Number: Claimant Social Security No.: Date of Accident: Claimant: Insurer/Self-Insurer: Employer:
The Counsel listed below, who currently represents the following party in the abovereferenced claim, requests that said attorney's appearance be stricken from this case:
Claimant Employer/Insurer SIF UEF Healthcare Provider
ATTORNEY INFORMATION: (Complete in Adobe Reader, type or print 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 Strike Appearance of Counsel was mailed to all parties and/or their attorneys.
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Signature
CLICK HERE TO CLEAR THE FORM
WCC Form C25R (Rev 08/28/03)
10 East Baltimore Street Baltimore, Maryland 21202-1641 410-864-5100 Email: [email protected] Web: http://www.wcc.state.state.md.us