Maryland > Workers Compensation > Adjudication Claims
Request For Reconsideration Or Modification H30R - Maryland
| Request For Reconsideration Or Modification Form. This is a Maryland form and can be used in Adjudication Claims Workers Compensation . |
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WORKERS COMPENSATION COMMISSION REQUEST FOR RECONSIDERATION/ MODIFICATION INSTRUCTIONS: This form is to be used b yparties to a compensation claim on to request thatly an Order be modified pursuant to L E9-736. Fill out this form completely and submit to the Commission without a cover letter. This form must be accompanied by Issues (WCC Form H24R). CLAIM NUMBER: CLAIMANT: EMPLOYER: INSURER: The undersigned par ttoy this Wobrkers Compensation Claim herey requests modification of the Order dated and as justification states: The claimant is entitled to additional temporary total benefits. The claimants permanent disability has increased. The claimants permanent disability has decreased. Other REQUESTED BY: FULL NAME S TREET ADDRESS CITY STATE Z IP CODE CLAIMANT CLAIMANTS ATTORNEY EMPLOYER/INSURER EMPLOYER/INSURERS ATTORNEY OTHER A copy of this form with supporting documentation, including Issues (H24R), has been sent to the other parties/attorneys to this action. ____________________________________ SIGNATURE DATE PHONE NUMBER WCC H30R (Rev) 09/01/03 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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