Maryland > Workers Compensation > Adjudication Claims
Request For A Hearing For Referral To Maryland Insurance Fraud Division H35R - Maryland
| Request For A Hearing For Referral To Maryland Insurance Fraud Division Form. This is a Maryland form and can be used in Adjudication Claims Workers Compensation . |
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WORKERS COMPENSATION COMMISSION REQUEST FOR A HEARING FOR REFERRAL TO MARYLAND INSURANCE FRAUD DIVISION This form may be filed by any party at any time. The Commission shall refer the case on the person named below to the Ins urance Fraud Division in the Maryland Insurance Administration where the Commission finds, after a he aring, that the party requesting the referral has carried the burden of establishing by a preponderance o f the evidence that the named person knowingly affected or knowingly attempted to affect the payment of compensation, fees, or expenses under Title 9 of the Labor Law by means of a fraudulent represe ntation. The undersigned alleges that the person named below violated section 9-310.2(a) of the Labor & Employment Article and requests a hearing before the Commission. Information on Person to be Referred Employee/Claimant Employer Insurer Health Care Provider Other Name Address: Street City State Zip Code Social Security (if known/applicable) Claim Number (if known/applicable) Party Requesting a Hearing Employee/Claimant Employer Insurer Health Care Provider Other Name Title (if applicable) Address: Street City State Zip Code Telephone Number Signature Date MD WCC H35R Version 12/15/04 American LegalNet, Inc. www.USCourtForms.com
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