Maryland > Workers Compensation > Adjudication Claims
Request To Enter Appearance Of Counsel C24R - Maryland
| Request To Enter Appearance Of Counsel Form. This is a Maryland form and can be used in Adjudication Claims Workers Compensation . |
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WORKERS COMPENSATION COMMISSION REQUEST TO ENTER APPEARANCE OF COUNSEL This form may NOT be used on behalf of an employer or insurer. WCC Claim Number: Claimants Social Security No: Date of Accident: Claimant: On Behalf of: Claimant SIF UEF Healthcare Provider ATTORNEY INFORMATION: (Complete in Adobe Reader, Print or Type Only) Name of Counsel: WCC Attorney Registration No: Street Address: City/State/Zip: Telephone: I hereby certify that on this day of 20 , ,a copy of this Request to Enter Appearance of Counsel was mailed to all parties and/or their attorneys. ___________________________________ Signature WCC FoCrm 24R (Rev. 0828//03) 10 East Baltimore Street x Baltimore, Maryland 21202-1641 410-864-5100 x Email: info@wcc.state.md.us x Web: http://www.wcc.state.md.us
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