Free MD WCC Request for a hearing for Referral to the Maryland Insurance Fraud Division - Maryland

WORKERS' COMPENSATION COMMISSION

REQUEST FOR A HEARING FOR REFERRAL TO MARYLAND INSURANCE FRAUD DIVISION
This form may be filed by any party at any time. The Commission shall refer the case on the person named below to the Insurance Fraud Division in the Maryland Insurance Administration where the Commission finds, after a hearing, that the party requesting the referral has carried the burden of establishing by a preponderance of the evidence that the named person knowingly affected or knowingly attempted to affect the payment of compensation, fees, or expenses under Title 9 of the Labor Law by means of a fraudulent representation. The undersigned requests a hearing before the Commission pursuant to section 9-310.2(a) of the Labor & Employment Article.

Information on Person to be Referred
Employee/Claimant Insurer Name Address: Street City Social Security (if known/applicable) Claim Number (if known/applicable) State Zip Code Employer Other Health Care Provider

Party Requesting a Hearing
Employee/Claimant/Attorney Insurer/Attorney* Employer Other Health Care Provider Yes No

Has this matter been referred to law enforcement pursuant to Insurance § 27-802?
* Must include contact information for insurer personnel familiar with fraud allegations.

Name Title (if applicable) Address: Street City Telephone Number Signature Date State Zip Code

CLICK HERE TO CLEAR THE FORM
10 East Baltimore Street Baltimore, Maryland 21202-1641 410-864-5100 Email: [email protected] Web: http://www.wcc.state.md.us
MD WCC H-35 (02/09/2007) .