Maryland > Workers Compensation > Adjudication Claims
Request To Implead A Party H33R - Maryland
| Request To Implead A Party 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 This form is to be used to implead additional parties in a claim. It does not initiate a hearing. An appropriate WCC form, such as "Issues" form H24R, must be filed to facilitate a hear ing before a WCC Commissioner. WCC CLAIM NUMBER: CLAIMANTS NAME : EMPLOYER: INSURER: If hearing has been scheduled: DATE LOCATION REQUEST TO THE COMMISSION : The undersigned party to this Workers Compensation Claim hereby requ ests that thefoll owing party be impleaded: Employer Statutory Employer Insurance Carrier SIF UEF Name: Address: City State Zip Code Carrier, Policy Number (if known)- REQUESTED BY: Claimant Claimants Attorney Employer Employers Attorney Insurers Attorney SIF UEF Full Name Address City State Zip Code CE RT IFICATION OF SERVI C E I hereby cer tify that on this d ay of , , a copy of this Request to Implead a Party was mailed to all parties and their attorneys. Signature Date Telephone 10 East Baltimore Street Baltimore, Maryland 21202-1641 410-864-5100 Email: info@wcc.state.md.us Web: http://www.wcc.state.md.us WCC Form H-33R (10/12/04)
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