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. Do not use this form to implead the the Maryland Property & Casualty Insurance Guaranty Corporation (PCIGC) 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: Carrier, Policy Number (if known)- *See COMAR 14.09.01.13 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 410-864-5100 Email: info@wcc.state.md.us Web: http://www.wcc.state.md.us WCC Form H-33R (10/14//08) American LegalNet, Inc. www.FormsWorkFlow.com