Free Request for Modification - Maryland


File Size: 66.4 kB
Pages: 1
Date: July 18, 2005
File Format: PDF
State: Maryland
Category: Workers Compensation
Author: Webmaster
Word Count: 189 Words, 1,254 Characters
Page Size: Letter (8 1/2" x 11")
URL

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

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WORKERS' COMPENSATION COMMISSION

REQUEST FOR MODIFICATION
INSTRUCTIONS: This form is to be used by parties to a compensation claim only to request that an Order be reconsidered, reopened or modified pursuant to LE 9-736. Fill out this form completely and submit to the Commission without a cover letter. This form must be accompanied by Issues (WCC Form H24R). CLAIM NUMBER: EMPLOYER: INSURER: The undersigned party to this Workers' Compensation Claim hereby requests modification of the Order dated and as justification states: The claimant is entitled to additional temporary total benefits. The claimant's permanent disability has increased. The claimant's permanent disability has decreased. Other CLAIMANT:

REQUESTED BY:
FULL NAME STREET ADDRESS CITY STATE ZIP CODE

CLAIMANT

CLAIMANT'S ATTORNEY

EMPLOYER/INSURER OTHER

EMPLOYER/INSURER'S ATTORNEY

A copy of this form with supporting documentation, including Issues (H24R), has been sent to the other parties/attorneys to this action.

____________________________________
SIGNATURE
WCC H30R (Rev July 2005)

DATE

PHONE NUMBER

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