Free emer hrg postponement _H29R_.DOC - Maryland

WORKERS' COMPENSATION COMMISSION

REQUEST FOR POSTPONEMENT OF

EMERGENCY HEARING
INSTRUCTIONS: This form is to be used by parties to a compensation claim only to request that a scheduled emergency hearing be continued or postponed. Fill out this form as completely as possible and submit to the Commission for appropriate action. The form is to be used only to request an emergency hearing continuance, and is to be submitted without a cover letter. *The Commission does not accept FAXed documents.

REQUEST TO THE COMMISSION The undersigned party to this Workers' Compensation Claim hereby requests that the emergency hearing scheduled for the date and location described below be continued for the reason(s) specified.

CLAIM IDENTIFICATION
CLAIM NUMBER: EMPLOYER:
INSURER:

CLAIMANT'S NAME:

CURRENTLY SCHEDULED HEARING INFORMATION
HEARING DATE: LOCATION:

JUSTIFICATION/REASON FOR CONTINUANCE:
500 CHARACTERS

POSTPONEMENT REQUESTED BY:

___________________________
FULL NAME SIGNATURE DATE OF REQUEST

CLAIMANT
ADDRESS:
STREET

CLAIMANT'S ATTY

EMPLOYER/INSURER

EMP/INS ATTY

OTHER:
TELE :

CITY

STATE

ZIP CODE

CERTIFICATE OF SERVICE

I HEREBY CERTIFY that on this th day of Emergency Hearing Request for Postponement was sent by fax

, , a copy of the aforesaid or first class mail postage prepaid to:

CLAIMANT
SENT FROM:

CLAIMANT'S ATTY

EMPLOYER/INSURER

EMP/INS ATTY

OTHER:
TELE:

STREET, CITY, STATE, ZIP CODE

WCC Form H29R (8/28/03)

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

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