Request To Implead Party In Uninsured Employers (UEF) Claim
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Request To Implead Party In Uninsured Employers (UEF) Claim Form. This is a Maryland form and can be use in Adjudication Claims Workers Compensation.
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Tags: Request To Implead Party In Uninsured Employers (UEF) Claim, H32R, Maryland Workers Compensation, Adjudication Claims
COURT
COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
......... ..
:
Index No.
WORKERS’ COMPENSATION COMMISSION
:
Calendar No.
REQUEST TO IMPLEAD A PARTY
:
Plaintiff(s)
IN AN UNINSURED EMPLOYER’SJUDICIAL SUBPOENA
(UEF) CLAIM
-against-
:
INSTRUCTIONS: This form is to be used to implead additional parties in a claim, in which the
:
Uninsured Employers’ Fund has been named as a party. To implead additional parties not involving the
Uninsured Employers’ Fund, use form H25R, Request for Action on Filed Issues.
:
WCC CLAIM #:
CLAIMANT:
Defendant(s)
:
......................................................
DATE OF ACCIDENT:
REQUEST TO THE COMMISSION
THE PEOPLE OF THE STATEWorkers’ Compensation claim requests that the following party be impleaded:
The undersigned party to this OF NEW YORK
Name:
TO
Address:
Street
GREETINGS:
City
State
Zip Code
WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before
,
the Honorable
at the
Court
Insurance Carrier Info:
located at
County of #, if known:
Policy
in room
, on the
day of
, 20
, at
o'clock in the
noon, and at any recessed
or adjourned date, to testify and give evidence as a witness in this action on the part of the
Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to
the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a
result of your failure to comply.
The party to be impleaded is alleged to be:
An EmployerHonorable A Statutory Employer
Witness,
Court in
County,
day of
A Co-Employer of theAn Insurance Carrier
, one
Justices of the
, 20
REQUESTED BY: FULL NAME
(Attorney must sign above and type name below)
ADDRESS: Street
City
State
CLAIMANT
Zip Code
CLAIMANT’S ATTORNEY Attorney(s) for
EMPLOYER
EMPLOYER’S ATTORNEY
UEF
INSURER’S ATTORNEY
Office and P.O. Address
I hereby certify that a copy of this request has been sent to all parties/attorneys to this claim.
__________________________________
SIGNATURE
TelephoneTELEPHONE NUMBER
No.:
DATE
Facsimile No.:
10 East Baltimore Street q Baltimore, Maryland 21202-1641
E-Mail Address:
410-864-5100 q Email: info@wcc.state.md.us qWeb: http://www.wcc.state.md.us
Mobile Tel. No.:
WCC H32R (Rev. 9/05/03)
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