Free COVER SHEET FOR ACTION ON CLAIMS ON APPEAL MD WCC H-11 AOA - Maryland

WORKERS' COMPENSATION COMMISSION
COVER SHEET FOR ACTION ON CLAIMS ON APPEAL
Instructions: This form must be accompanied by a True Test copy of the Appellate Court's Order and Case Docket Entry. If a hearing is required, you must also file Issues Form H24 for the matter to be put in line.

To: Appeals Division Is this a claim remanded from the Circuit Court? Claimant's Name: WCC Claim #: County: Name of Presiding Judge: Name of Filing Party: COURT OF SPECIAL APPEALS Yes

Date: Yes No

No

ACTION TAKEN: (True test copy of Judge's Order & Case Docket Entry must be attached.) AFFIRM REVERSED WITHDRAWN REMAND for further proceedings
(attach Issues form H-24)

MODIFY Remarks:

DISMISSED

ATTORNEY FEE PETITION (must be attached) Remarks:

Submitted by:

Printed Name

Signature

Telephone Number

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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 H-11-AOA 06/20/08 .