Request For Postponement Of Emergency Hearing {H29R}

WORKERS COMPENSATION COMMISSION REQUEST FOR POSTPONEMENT OF EMERGENCY HEARING INSTRUCTIONS: This form is to be used by parties to a compensation claim only to reque st that a scheduled emergency hearing be continued or postponed. Fill out this form as completely as possible and submit to th e Commission for appropriate action. The form is to be used only to request an emergency hearing continuance, and is to be submitted without a cover letter. *The Commission does not accept FAXed documents. REQUEST TO THE COMMISSION Th e undersigned party to this Workers Compen sation Claim hereby requests that the emergency hearing schedul edfor the date and location described below be continued for the reason(s) specifide. CLAIM IDENTIFICATION CLAIM NUMBER: CLAIMANTS NAME: EMPLOYER: INSURER: CURRENTLY SCHEDULED HEARING INFORMATION HEARING DATE: LOCATION: JUSTIFICATION/REASON FOR CONTINUANCE: POSTPONEMENT REQUESTED BY: ___________________________ FULL NAME SIGNATURE DATE OF REQUEST CLAIMANT CLAIMANTS ATTY EMPLOYER/INSURER EMP/INS ATTY OTHER: ADDRESS: TELE : STREET CITY STATE ZIP CODE CERTIFICATE OF SERVICE I HEREBY CERTIFY that on this th day of , , a copy of the aforesaid Emergency Hearing Request for Postponement was sent by fax or first class mail postage prepaid to: CLAIMANT CLAIMANTS ATTY EMPLOYER/INSURER EMP/INS ATTY OTHER: SENT FROM: TELE: STREET, CITY, STATE, ZIP CODE 10 East Baltimore Street l Baltimore, Maryland 21202-1641 WCC Form H29R (8/28/03) 410-864-5100 l Email: info@wcc.state.md.us l Web: http://www.wcc.state.md.us