Request For Reconsideration Or Modification
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Request For Reconsideration Or Modification Form. This is a Maryland form and can be use in Adjudication Claims Workers Compensation.
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Tags: Request For Reconsideration Or Modification, H30R, Maryland Workers Compensation, Adjudication Claims
WORKERS’ COMPENSATION COMMISSION
REQUEST FOR MODIFICATION
INSTRUCTIONS: This form is to be used by parties to a compensation claim only to request that an Order be
reconsidered, reopened or modified pursuant to LE §9-736. Fill out this form completely and submit to the
Commission without a cover letter. This form must be accompanied by Issues (WCC Form H24R).
CLAIM NUMBER:
CLAIMANT:
EMPLOYER:
INSURER:
The undersigned party to this Workers’ Compensation Claim hereby requests modification of the Order
dated
and as justification states:
The claimant is entitled to additional temporary total benefits.
The claimant’s permanent disability has increased.
The claimant’s permanent disability has decreased.
Other
REQUESTED BY:
FULL NAME
STREET ADDRESS
CITY
CLAIMANT
STATE ZIP CODE
CLAIMANT’S ATTORNEY
EMPLOYER/INSURER’S ATTORNEY
EMPLOYER/INSURER
OTHER
A copy of this form with supporting documentation, including Issues (H24R), has been sent to the other
parties/attorneys to this action.
____________________________________
SIGNATURE
WCC H30R (Rev July 2005)
DATE
PHONE NUMBER
CLICK HERE TO CLEAR THE FORM
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
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