Maryland > Workers Compensation > Adjudication Claims
Issues H24R - Maryland
| Issues Form. This is a Maryland form and can be used in Adjudication Claims Workers Compensation . |
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WORKERS' COMPENSATION COMMISSION ISSUES Claim Number Claimant Name Employer Insurer The following issues are hereby raised by (choose one) Claimant Employer's Attorney Claimant's Attorney Insurer Employer Insurer's Attorney Non Insurer Non Insurer's Attorney SIF UEF Date 1. Did the employee sustain an injury causally related to an accident which arose out of and in the course of employment? 2. Is the disability of the employee (TT/TP/PT/PP) causally related to the accidental injury? 3. Did the employee sustain a compensable hernia within the meaning of the Workers' Compensation Act? 4. Did the employee sustain an occupational disease? 5. Average weekly wage 6. Limitations 7. Jurisdiction 8 Statutory employment 9. Medical expenses (creditors and/or amount) 10. Vocational rehabilitation 11. Attorney fees/costs 12. Penalties 13. Temporary total disability from to 14. Nature and extent of permanent disability to the following part or parts of the body: 15. Other (specify) 16. Authorization for medical treatment (you must briefly specify treatment requested) 17. Temporary total from to present and continuing. I hereby certify that on this day of , documentation was mailed to all parties and their attorneys. a copy of the above issues and any attached Name of Party Raising Issues Signature 10 East Baltimore Street Baltimore, Maryland 21202-1641 410-864-5100 Email: info@wcc.state.md.us Web: http://www.wcc.state.md.us WCC Form H24R (9/19/2011) American LegalNet, Inc. www.FormsWorkFlow.com
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