Maryland > Workers Compensation > Adjudication Claims
Request To Strike Appearance Of Counsel C25R - Maryland
| Request To Strike 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 STRIKE APPEARANCE OF COUNSEL WCC Claim Number: Claimant Social Security No .: Date of Accident: Claimant: Insurer/Self-Insurer: Employer: The Counsel listed below, who currently represents the following party in the above-referenced claim, requests that said attorneys appearance be stricken f rom this case: Claimant Employer/Insurer SIF UEF Healthcare ProviderATTORNEY INFORMATION: (Complete in Adobe Reader, type or print 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 Strike Appearance of Counsel was mailed to all parties and/or their attorneys. ___________________________________ Signature WCC FoCrm 25R (Rev 08/28/03) 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.state.md.us
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