REQUEST FOR ACTION ON FILED ISSUES
This form is to be used only for the actions identified below and is to be submitted without a cover letter.
WCC CLAIM NUMBER: CLAIMANT'S NAME: EMPLOYER: INSURER: If hearing has been scheduled: DATE LOCATION
SELECT ONLY ONE ACTION:
Withdrawal of issues previously filed (Filing party only). Dismissal of claim (On behalf of claimant only). "Set With" scheduling:
The following numbered claim(s) have pending issues and should be set with this claim when it is scheduled for hearing:
Change of Venue:
Requestor MUST complete the Location and Date Information above
Requested Location: Reason for Change:
Claimant Claimant'sAttorney Employer/Insurer Employer/InsurerAttorney SIF/UEF
CERTIFICATION OF SERVICE I hereby certify that on this day of , , a copy of this Request and any attached documentation was mailed to all parties and their attorneys. Failure to notify opposing counsel prior to the hearing date may result in a penalty or fine to be assessed against a party withdrawing issues.
Name Telephone Number
WCC Form H25R ( February 2007)
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10 East Baltimore Street Baltimore, MD 21202-1641 410-864-5100 Email: [email protected] Web: http://www.wcc.state.md.us