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Request To Implead Party In Uninsured Employers (UEF) Claim H32R - Maryland
| Request To Implead Party In Uninsured Employers (UEF) Claim Form. This is a Maryland form and can be used in Adjudication Claims Workers Compensation . |
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WORKERS COMPENSATION COMMISSION REQUEST TO IMPLEAD A PARTY IN AN UNINSURED EMPLOYERS (UEF) CLAIM INSTRUCTIONS: This form is to be used to implead additional parties in a claim, in which the Uninsured Employers Fund has been named as a party. To implead additional parties not involving the Uninsured Employers Fund, use form H25R, Request for Action on Filed Issues. WCC CLAIM #: CLAIMANT: DATE OF ACCIDENT: REQUEST TO THE COMMISSION The undersigned party to this Workers Compensation claim requests th at the following party be impleaded: Name: Address: Street City State Zip Code Insurance Carrier Info: Policy #, if known: The party to be impleaded is alleged to be: An Employer A Statutory Employer A Co-Employer An Insurance Carrier REQUESTED BY: FULL NAME ADDRESS: Street City State Zip Code CLAIMANT CLAIMANTS ATTORNEY EMPLOYER UEF EMPLOYERS ATTORNEY INSURERS ATTORNEY I hereby certify that a copy of this request has been sent to all partie s/attorneys to this claim. __________________________________ SIGNATURE DATE TELEPHONE NUMBER 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 WCC H32R (Rev. 9/05/03)
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