WORKERS' COMPENSATION COMMISSION
REQUEST TO IMPLEAD A PARTY
INSTRUCTIONS: This form is to be used to implead additional parties in a claim. It does not initiate a hearing. An appropriate WCC form, such as "Issues" form H24R, must be filed to schedule a hearing.
WCC CLAIM NUMBER: CLAIMANT'S NAME: EMPLOYER: INSURER: If hearing has been scheduled: DATE LOCATION REQUEST TO THE COMMISSION:
The undersigned party to this Workers' Compensation Claim requests that the following party be impleaded:
Employer
Statutory Employer
Insurance Carrier
SIF*
UEF
Name: Address: *See COMAR 14.09.01.13
Carrier, Policy Number (if known)-
REQUESTED BY:
Claimant Insurer Claimant's Attorney Insurer's Attorney Employer SIF Employer's Attorney UEF
Full Name Address
City State ZIP Code
CERTIFICATION OF SERVICE I hereby certify that on this day of ,2 Implead a Party was mailed to all parties and their attorneys. , a copy of this Request to
Signature
Date
Telephone
10 East Baltimore Street Baltimore, Maryland 21202-1641 Click Here to Reset This Form 410-864-5100 Email: [email protected] Web: http://www.wcc.state.md.us
WCC Form H-33R (10/14//08)