WORKERS' COMPENSATION COMMISSION
REQUEST FOR REHEARING
INSTRUCTIONS: This form is to be used by parties to a compensation claim only to request reconsideration of a prior decision of the Commission pursuant to LE ยง9-726. The Request must be based on an alleged error of law or a mistake of fact and must be filed within 15 days after the decision. CLAIM NUMBER: EMPLOYER: INSURER: The undersigned party to this Workers' Compensation Claim hereby requests a rehearing of the decision dated and as justification states: CLAIMANT:
REQUESTED BY:
FULL NAME STREET ADDRESS
CITY
STATE
ZIP CODE
CLAIMANT
CLAIMANT'S ATTORNEY OTHER
EMPLOYER/INSURER
EMPLOYER/ INSURER ATTORNEY
A copy of this form with supporting documentation, including Issues, has been sent to the other parties/attorneys to this action.
_____________________________
SIGNATURE DATE TELEPHONE NUMBER
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WCC H27R (Rev. 9/02/03)
10 East Baltimore Street q Baltimore, Maryland 21202-1641 410-864-5100 q Email: [email protected] qWeb: http://www.wcc.state.md.us