Free MD WCC Request for Rehearing H27R - Maryland


File Size: 89.4 kB
Pages: 1
File Format: PDF
State: Maryland
Category: Workers Compensation
Author: MD WCC Webmaster
Word Count: 167 Words, 1,059 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.wcc.state.md.us/PDF/PDF_Forms/eRehearing.pdf

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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 9-726. 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

CLICK HERE TO CLEAR THE FORM
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