Maryland > Workers Compensation > Adjudication Claims
Request For Action On Filed Issues H25R - Maryland
| Request For Action On Filed Issues Form. This is a Maryland form and can be used in Adjudication Claims Workers Compensation . |
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WORKERS COMPENSATION COMMISSION REQUEST FOR ACTION ON FILED ISSUES This form is to be used only for the actions identified below and is to be submitted without a cover letter. WCC CLAIM NUMBER: CLAIMANTS NAME: EMPLOYER: INSURER: SELECT ONLY ONE ACTION: Withdrawal of issues previously filed (Filing party only). If hearing has been scheduled: DATE LOCATION Dismissal of claim (On behalf of Claimant only). Set With scheduling: The following numbered claim(s) have pending issues and should be set with this claim when it is scheduled for hearing: Implead the following party: Include proper name/address of the employer when impleading additional employers. If known, include name of carrier. Other: REQUESTED BY: Claimant Claimants Attorney Employer/Insurer E mployer/Insurer Attorney SIF/UEF Full Name Telephone Number ___________________________________ Signature Date of Request WCC Form H25R ( Rev 08/28/03 ) 10 East Baltimore Street Baltimore, MD 21202-1641 410-864-5100 Email: info@wcc.state.md.us Web: http://www.wcc.state.md.us
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