Free MD WCC REQUEST FOR CONTINUANCE OF HEARING WCC Form H28R - Maryland

WORKERS' COMPENSATION COMMISSION

REQUEST FOR CONTINUANCE OF HEARING
INSTRUCTIONS: The form is to be used only to request a continuance of a scheduled hearing, and is to be submitted without a cover letter.

REQUEST TO THE COMMISSION
The undersigned hereby requests that the hearing scheduled for the date and location described below be continued for the reason(s) specified.

CLAIM IDENTIFICATION
CLAIM NUMBER: CLAIMANT'S NAME: EMPLOYER: INSURER:

CURRENTLY SCHEDULED HEARING INFORMATION HEARING DATE: LOCATION: DATE OF HEARING NOTICE: JUSTIFICATION/REASON FOR CONTINUANCE:

I hereby certify that a copy of this request and its documentation has been sent to opposing counsel/parties, and also certify that the opposing counsel/parties has been contacted and they: 1) object 2) consent 3) No response to attempted contact . REQUESTED BY

_____________________________
FULL NAME (PRINT OR TYPE) SIGNATURE DATE OF REQUEST

CLAIMANT

CLAIMANT'S ATTY

EMPLOYER/EMP ATTY

INSURER ATTY

UEF/SIF

ADDRESS :
STREET

TEL:

CITY
q

STATE

ZIP

10 East Baltimore Street Baltimore, Maryland 21202-1641 410-864-5100 q Email: [email protected] qWeb: http://www.wcc.state.md.us
WCC Form H28R (Rev. 01/28/2008)

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