Request For Document Correction {C90R}

Workers Compensation Commission REQUEST FOR DOCUMENT CORRECTION REQUEST FOR DOCUMENT CORRECTION INSTRUCTIONS: This form is to be used by parties to a compensation claim to notify the Commission that an error exists in a document, which has been filed with the agency pertaining to a specific workers compensation claim. The nature of the error and/or who caused the error is irrelevant. The mistake may have been reflected on the document originally or may have been caused by character transposition or due to human error in either reading or application. The purpose in submitting the form is simply to get the mistake corrected as expeditiously as possible . Any individual identifying an error on a document in the Commissions files (paper or electronic) is requested to fill out this form as completely as poss ible and submit it to the Commission for appropriate corrective action. The form should be submitted without a cover letter. The form is to be used only for the correction of errors regarding factual matters not in dispute. For example, if a Date of Accident as originally submitted on a claim form is found to be incorrect, and all concerned con-cede that the original date was wrong, this form may be used to obtain a correction in the Commissions recor ds. If, however, a factual dispute exists with respect to the Date of Accident and the party originally submitting the information believes it is factually accurate, the matter should not be categorized as a document correction. The dispute should be resolved at a hearing together with other matters upon which the parties do not agree. NOTICE TO THE COMMISSION An error has been identified in a claim document on file with the Workers Compensation Commission as described below. This submission requests that corrective action be taken as soon as poss ible. DOCUMENT IDENTIFICATION C LAI MNUMBER: DOCUMENT TYPE: CLAIMANTS NAME: DOCUMENT DATE: ERROR DESCRIPTION: CORRECTION REQUESTED: R EQUESTED BY: FULL NAME SIGNATURE DATE OF RE QUEST CLAIMANT CLAIMANTS ATTY EMPLOYER/INSURER EMP/INS ATTY OTHER: 10 East Baltimore Street l Baltimore, Maryland 21202-1641 WCC C90R (8/28/03) 410-864-5100 l Email: info@wcc.state.md.us l Web: http://www.wcc.state.md.us