Free MD WCC Request to Implead a Party H-33R (print only) - Maryland

WORKERS' COMPENSATION COMMISSION

REQUEST TO IMPLEAD A PARTY
INSTRUCTIONS: This form is to be used to implead additional parties in a claim. It does not initiate a hearing. An appropriate WCC form, such as "Issues" form H24R, must be filed to schedule a hearing.

WCC CLAIM NUMBER: CLAIMANT'S NAME: EMPLOYER: INSURER: If hearing has been scheduled: DATE LOCATION REQUEST TO THE COMMISSION:
The undersigned party to this Workers' Compensation Claim requests that the following party be impleaded:

Employer

Statutory Employer

Insurance Carrier

SIF*

UEF

Name: Address: *See COMAR 14.09.01.13

Carrier, Policy Number (if known)-

REQUESTED BY:
Claimant Claimant's Attorney SIF Employer UEF Employer's Attorney

Insurer's Attorney

Full Name Address
City State ZIP Code

CERTIFICATION OF SERVICE I hereby certify that on this day of ,2 Implead a Party was mailed to all parties and their attorneys. , a copy of this Request to

Signature

Date

Telephone

10 East Baltimore Street w Baltimore, Maryland 21202-1641 410-864-5100 w Email: [email protected] w Web: http://www.wcc.state.md.us
WCC Form H-33R (10/14//08)