WORKERS' COMPENSATION COMMISSION DISAGREEMENT WITH PROPOSED VOCATIONAL REHABILITATION PLAN INSTRUCTIONS: This form is to be used to notify the Commission of a party's disagreement with a proposed vocational rehabilitation plan. This 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. CLAIM NUMBER: CLAIMANT NAME: EMPLOYER: INSURER: The undersigned Claimant/Claimant's Attorney Employer/Insurer's Attorney SIF/UEF Other a party to this Workers' Compensation Claim, having reviewed the proposed vocational rehabilitation plan, disagrees with the plan for the following reasons: BY: FULL NAME: ADDRESS: SIGNATURE: DATE OF REQUEST: CERTIFICATION OF SERVICE I hereby certify that on this ___ day of ,2 , I mailed, postage prepaid, a copy of this Disagreement with Proposed Vocational Rehabilitation Plan to all parties and their attorneys. 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 VR13R (04/14) American LegalNet, Inc. www.FormsWorkFlow.com