WORKERS COMPENSATION COMMISSION REQUEST FOR REHEARING INSTRUCTIONS: This form is to be used by parties to a compensation claim only to request reconsideration of a prior decision of the Commission pursuant to LE 9-726. The Request must be based on an alleged error of law or a mistake of fact and must be filed within 15 days after the decision. CLAIM NUMBER: CLAIMANT: EMPLOYER: INSURER: The undersigned party to this Workers Compensation Claim hereby requests a rehearing of the decision dated and as justification states : REQUESTED BY: FULL NAME STREET A DDRESS CITY STATE ZIP CODE CLAIMANT CLAIMANTS ATTORNEY EMPLOYER/INSURER EMPLOYER/ INSURER ATTORNEY OTHER A copy of this form with supporting documentation, including Issues, has been sent to the other parties/attorneys to this action. _____________________________ SIGNATURE DATE TELEPHONE NUMBER 10 East Baltimore Street l Baltimore, Maryland 21202-1641 WCC H27Re (Rv. 9/02/03) 410-864-5100 l Email: info@wcc.state.md.us l Web: http://www.wcc.state.md.us