Maryland > Workers Compensation > Adjudication Claims
Request For Emergency Hearing H26R - Maryland
| Request For Emergency Hearing Form. This is a Maryland form and can be used in Adjudication Claims Workers Compensation . |
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WORKERS COMPENSATION COMMISSION REQUEST FOR EMERGENCY HEARINGREQUEST FOR EMERGENCY HEARING INSTRUCTIONS: This form is to be used by parties to a compensation claim to request an Emergency Hearing relating to a compensation claim previously filed with the Commission, where facts and circumstance s warrant accelerated processing. Fill out this form as completelyas possible and submit it to the Commission for appropriate action. This form is to be used only to request an Emergency Hearing and is to be submitted without a cover letter. REQUEST TO THE COMMISSION Th eundersigned party to this Workers Compen sation Claim hereby requests that anE mergency Hearing be scheduled on this case as soon as possible. The requesting party warrants that a copy of this request and its enclosed documentati on have been sent to other parties to the action. CLAIM IDENTIFICATION CLAI MNUMBER: CLAI MANTS NAME: EMPLOYER: INSURER: JUSTIFICATION FOR EMERGENCY PROCESSING: E xpedited processing of this case is requested for the following reason(s): Documentation establishing the foregoing facts and circumstances is enclosed. *THIS REQUEST MUST BE ACCOMPANIED BY WCC ISSUES FORM H24R* RE QU ESTED BY: ____________________________ FULL NAME SIGNATURE DATE CLAIMANT CLAIMANTS ATTY EMPLOYER/INSURER EMP/INS ATTY OTHER: A DDRESS: STREET TELEPHONE CITY STATE ZIP CODE WCC H26R (Rev. 8/28/03) 10 East Baltimore Street l Baltimore, Maryland 21202-1641 410-864-5100 l Email: info@wcc.state.md.us l Web: http://www.wcc.state.md.us
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