Fill and Sign the Maryland Request Hearing Form

CLAIM NUMBER:      CLAIMANT'S NAME:       EMPLOYER:       INSURER:       HEARING DATE:       LOCATION:                         CLAIMANT CLAIMANT'S ATTY EMPLOYER/INSURER EMP/INS ATTY OTHER:       ADDRESS:             I HEREBY CERTIFY that on this       th day of             Emergency Hearing Request for Postponement was sent by fax     or first class mail           CLAIMANT CLAIMANT'S ATTY EMPLOYER/INSURER EMP/INS ATTY OTHER:       ADDRESS:             WORKERS' COMPENSATION COMMISSION 10 East Baltimore Street Baltimore, Maryland 21202-1641 REQUEST FOR POSTPONEMENT OF EMERGENCY HEARINGINSTRUCTIONS: 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 it 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. FAXED REQUESTS WILL ONLY BE ACCEPTED AT (410) 864-5101. 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 CURRENTLY SCHEDULED HEARING INFORMATION JUSTIFICATION/REASON FOR CONTINUANCE: 450 Characters POSTPONEMENT REQUESTED BY: FULL NAME SIGNATURE DATE OF REQUEST TELE STREET, CITY, STATE, ZIP CODE CERTIFICATE OF SERVICE: I , a copy of the aforesaid postage prepaid to: TELE: STREET, CITY, STATE, ZIP CODE WCC Form H29R (12/2000)