Maryland Request For Postponement Of Emergency Hearing wcc Hr by anthonycarter

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									                            WORKERS’ COMPENSATION COMMISSION

            REQUEST FOR POSTPONEMENT OF
               EMERGENCY HEARING
INSTRUCTIONS: This form is to be used by parties to a compensation claim only to request that a scheduled emergency hearing be continued or
postponed. Fill out this form as completely as possible and submit to the 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
   The undersigned party to this Workers’ Compensation Claim hereby requests that the emergency hearing
   scheduled for the date and location described below be continued for the reason(s) specified.

  CLAIM IDENTIFICATION
  CLAIM NUMBER:                                 CLAIMANT’S NAME:
   EMPLOYER:
   INSURER:
  CURRENTLY SCHEDULED HEARING INFORMATION
  HEARING DATE:                         LOCATION:

 JUSTIFICATION/REASON FOR CONTINUANCE:
 500 CHARACTERS




 POSTPONEMENT REQUESTED BY:

                                                                        ___________________________
  FULL NAME                                                             SIGNATURE                                            DATE OF REQUEST

      CLAIMANT              CLAIMANT’S 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             CLAIMANT’S ATTY               EMPLOYER/INSURER                    EMP/INS ATTY              OTHER:

 SENT FROM:                                                                                                          TELE:
              STREET, CITY, STATE, ZIP CODE


                                      10 East Baltimore Street q Baltimore, Maryland 21202-1641
  WCC Form H29R (8/28/03)
                             410-864-5100 q Email: info@wcc.state.md.us qWeb: http://www.wcc.state.md.us
                                                CLICK HERE TO CLEAR THE FORM

								
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