Request For Emergency Hearing {H26R}

WORKERS' COMPENSATION COMMISSION REQUEST FOR EMERGENCY HEARING INSTRUCTIONS: This form is to be used by parties to a compensation claim to request an Emergency Hearing relating to a compensation claim previously filed with the Commission, where facts and circumstances warrant accelerated processing. Fill out this form as completely as possible and submit it to the Commission for appropriate action. This form is to be used only to request an Emergency Hearing and is to be submitted without a cover letter. REQUEST TO THE COMMISSION The undersigned party to this Workers' Compensation Claim hereby requests that an Emergency Hearing be scheduled on this case as soon as possible. The requesting party warrants that a copy of this request and its enclosed documentation have been sent to other parties to the action. CLAIM IDENTIFICATION Claim Number: Consideration Date: Employer: Insurer: JUSTIFICATION FOR EMERGENCY PROCESSING: Expedited processing of this case is requested for the following reason(s): Documentation establishing the foregoing facts and circumstances is enclosed. *This request MUST be filed with a WCC Issues form H24R attached. REQUESTED BY: ____________________________ FULL NAME SIGNATURE DATE CLAIMANT ADDRESS: CLAIMANT'S ATTY EMPLOYER/INSURER EMP/INS ATTY OTHER: STREET TELEPHONE CITY WCC H26R (Rev. March 2012) STATE ZIP CODE 10 East Baltimore Street q Baltimore, Maryland 21202-1641 410-864-5100 q Email: info@wcc.state.md.us qWeb: http://www.wcc.state.md.us American LegalNet, Inc. www.FormsWorkFlow.com