WCC Form H30R "Request for Modification" - Maryland

What Is WCC Form H30R?

This is a legal form that was released by the Maryland Workers' Compensation Commission - a government authority operating within Maryland. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 2005;
  • The latest edition provided by the Maryland Workers' Compensation Commission;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of WCC Form H30R by clicking the link below or browse more documents and templates provided by the Maryland Workers' Compensation Commission.

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Download WCC Form H30R "Request for Modification" - Maryland

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WORKERS’ COMPENSATION COMMISSION
REQUEST FOR MODIFICATION
INSTRUCTIONS: This form is to be used by parties to a compensation claim only to request that an Order be
reconsidered, reopened or modified pursuant to LE §9-736. Fill out this form completely and submit to the
Commission without a cover letter.
This form must be accompanied by Issues (WCC Form H24R).
CLAIM NUMBER:
CLAIMANT:
EMPLOYER:
INSURER:
The undersigned party to this Workers’ Compensation Claim hereby requests modification of the Order
dated
and as justification states:
The claimant is entitled to additional temporary total benefits.
The claimant’s permanent disability has increased.
The claimant’s permanent disability has decreased.
Other
REQUESTED BY:
FULL NAME
STREET ADDRESS
CITY
STATE ZIP CODE
CLAIMANT
CLAIMANT’S ATTORNEY
EMPLOYER/INSURER
EMPLOYER/INSURER’S ATTORNEY
OTHER
A copy of this form with supporting documentation, including Issues (H24R), has been sent to the other
parties/attorneys to this action.
____________________________________
SIGNATURE
DATE
PHONE NUMBER
CLICK HERE TO CLEAR THE FORM
WCC H30R (Rev July 2005)
10 East Baltimore Street Baltimore, Maryland 21202-1641
410-864-5100 Email: info@wcc.state.md.us Web: http://www.wcc.state.md.us
WORKERS’ COMPENSATION COMMISSION
REQUEST FOR MODIFICATION
INSTRUCTIONS: This form is to be used by parties to a compensation claim only to request that an Order be
reconsidered, reopened or modified pursuant to LE §9-736. Fill out this form completely and submit to the
Commission without a cover letter.
This form must be accompanied by Issues (WCC Form H24R).
CLAIM NUMBER:
CLAIMANT:
EMPLOYER:
INSURER:
The undersigned party to this Workers’ Compensation Claim hereby requests modification of the Order
dated
and as justification states:
The claimant is entitled to additional temporary total benefits.
The claimant’s permanent disability has increased.
The claimant’s permanent disability has decreased.
Other
REQUESTED BY:
FULL NAME
STREET ADDRESS
CITY
STATE ZIP CODE
CLAIMANT
CLAIMANT’S ATTORNEY
EMPLOYER/INSURER
EMPLOYER/INSURER’S ATTORNEY
OTHER
A copy of this form with supporting documentation, including Issues (H24R), has been sent to the other
parties/attorneys to this action.
____________________________________
SIGNATURE
DATE
PHONE NUMBER
CLICK HERE TO CLEAR THE FORM
WCC H30R (Rev July 2005)
10 East Baltimore Street Baltimore, Maryland 21202-1641
410-864-5100 Email: info@wcc.state.md.us Web: http://www.wcc.state.md.us