Maryland > Workers Compensation > Adjudication Claims
Cover Sheet For Action On Claims On Appeal - Maryland
| Cover Sheet For Action On Claims On Appeal Form. This is a Maryland form and can be used in Adjudication Claims Workers Compensation . |
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WORKERS' COMPENSATION COMMISSION COVER SHEET FOR ACTION ON CLAIMS ON APPEAL Instructions: This form must be accompanied by a True Test copy of the Appellate Court's Order and Case Docket Entry. If a hearing is required, you must also file Issues Form H24 for the matter to be put in line. To: Appeals Division Is this a claim remanded from the Circuit Court? Claimant's Name: WCC Claim #: County: Name of Presiding Judge: Name of Filing Party: COURT OF SPECIAL APPEALS Yes Date: Yes No No ACTION TAKEN: (True test copy of Judge's Order & Case Docket Entry must be attached.) AFFIRM REVERSED WITHDRAWN REMAND for further proceedings (attach Issues form H24) MODIFY DISMISSED Remarks: ATTORNEY FEE PETITION (must be attached) Remarks: Submitted by: Printed Name Signature Telephone Number 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 H-11-AOA 06/20/08 . American LegalNet, Inc. www.FormsWorkflow.com
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