WORKERS' COMPENSATION COMMISSION NOTICE OF VOCATIONAL REHABILITATION PLAN CONTROVERSION OR ACCEPTANCE INSTRUCTIONS: This form is to be used to notify the Commission of a party's acceptance or controversion of a proposed vocational rehabilitation plan. The form must be completed and returned to the Commission no later than 15 days from the date of the letter which transmitted the proposed plan to the parties. The form is to be used only for the actions identified below, and is to be submitted without a cover letter. CLAIM NUMBER: CLAIMANT NAME: EMPLOYER: INSURER: The undersigned party to this Workers’ Compensation Claim, having reviewed the proposed vocational rehabilitation plan relating to the claim identified below, hereby Controverts the proposed plan and requests that a hearing be scheduled as soon as possible on the issue of the claimant’s vocational rehabilitation. Accepts the proposed plan and agrees to its terms. The Commission is requested to issue an appropriate order. CERTIFICATION OF SERVICE I hereby certify that on this day of , 2 , a copy of this Proposed Vocational Rehabilitation Plan Acceptance/Controversion was mailed to all parties and their attorneys. EMPLOYER/INSURER FULL NAME EMPLOYER/INSURER ATTORNEY OTHER: SIGNATURE DATE OF REQUEST ADDRESS Street City State ZIP Code 10 East Baltimore Street w Baltimore, Maryland 21202-1641 410-864-5100 w Email: info@wcc.state.md.us w Web: http://www.wcc.state.md.us MD WCC VR 13R 08/06/08 American LegalNet, Inc. www.FormsWorkflow.com