Maryland > Workers Compensation > Adjudication Claims
Request For A Hearing On Previously Withdrawn Issues H-12 - Maryland
| Request For A Hearing On Previously Withdrawn Issues Form.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WORKERS' COMPENSATION COMMISSION Request for a Hearing on Previously Withdrawn Issues INSTRUCTIONS: This form is to be used by parties to a compensation claim to request a hearing on specific issues previously filed and withdrawn within the past 90 days. This form serves as a request for such issues to be filed prior to the 90-day waiting requirement. WCC Issues form H24R must be attached to this form. WCC CLAIM NUMBER: CLAIMANT: EMPLOYER: INSURER: Exemption from the 90-day waiting requirement is requested for the following reason(s): Any documentation establishing the foregoing facts and circumstances is attached. Filed by: ADDRESS: CLAIMANT/CLAIMANT'S ATTY EMPLOYER/INSURER or EMP/INS ATTY STREET CITY TELEPHONE NUMBER STATE ZIP Code CERTIFICATION OF SERVICE I hereby certify that on this day of ,2 , a copy of this Request and its attached documentation was mailed to all parties and their attorneys. I further certify that this Request for a waiver of 90-day waiting requirement has not been previously filed. Name Signature 10 East Baltimore Street ! Baltimore, Maryland 21202-1641 410-864-5100 ! Email: info@wcc.state.md.us ! Web: http://www.wcc.state.md.us MD WCC Form H-12 02/15/2007 . American LegalNet, Inc. www.FormsWorkflow.com
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