Free MD WCC Request for a Hearing on Previously Withdrawn Issues - Maryland

WORKERS' COMPENSATION COMMISSION Request for a Hearing on Previously Withdrawn Issues
INSTRUCTIONS: This form is to be used by parties to a compensation claim to request a hearing on specific issues previously filed and withdrawn within the past 90 days. This form serves as a request for such issues to be filed prior to the 90-day waiting requirement. WCC Issues form H24R must be attached to this form.

WCC CLAIM NUMBER: CLAIMANT: EMPLOYER: INSURER:
Exemption from the 90-day waiting requirement is requested for the following reason(s):
Any documentation establishing the foregoing facts and circumstances is attached.

Filed by:
ADDRESS:

CLAIMANT/CLAIMANT'S ATTY

EMPLOYER/INSURER or EMP/INS ATTY

STREET CITY TELEPHONE NUMBER STATE ZIP Code

CERTIFICATION OF SERVICE I hereby certify that on this 1 day of January , 2 , a copy of this Request and its February attached documentation was mailed to all parties and their attorneys. I further certify that this Request for a waiver of 90-day waiting requirement has not been previously filed.

Name

Signature

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10 East Baltimore Street ! Baltimore, Maryland 21202-1641 410-864-5100 ! Email: [email protected] ! Web: http://www.wcc.state.md.us
MD WCC Form H-12 02/15/2007 .