Claim For Funeral Benefits Only Page 2
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2WORKERS' COMPENSATION COMMISSION
CLAIM FOR FUNERAL BENEFITS ONLY
IMPORTANT: It is the filing party's responsibility to maintain a current mailing address with the
Commission. The Commission Claim Number should be included on all correspondence.
Disclosure Pursuant to COMAR 01.01.1983.18
1. The personal information requested on this form is intended to be used in processing your claim under the Maryland workers’
compensation laws.
2. Failure to provide the information requested may result in your claim being rejected or a delay in the processing of your claim.
3. You may have a right to inspect, amend and correct the information provided on this form pursuant to State Government Article, §10-
624, Annotated Code of Maryland.
4. This form will be made part of your claim file. Portions of your claim file may be subject to public inspection.
5. The information contained on this form is routinely shared with State, Federal or local agencies.
Claim for Funeral Benefits Only Filing Instructions
This form may not be used if there are any dependent claimants. To file a claim for funeral benefits
only, this form must be completed, signed and filed. A Certification of Funeral Expenses (WCC Form
C-18) must be attached (see instruction 9 below). The Commission does not accept any claim forms,
documents or claim-related information via facsimile (FAX) or email.
All spaces MUST be typed or hand printed as clearly as possible in dark or black ink or downloaded from
1.
our web page, completed in Adobe Reader and printed from your personal computer (PC).
Provide all requested information.
2.
Dates must be filled in MM/DD/YYYY (month-day-year) format.
3.
When numeric information is not available, zeros MUST be entered. For example, Social Security Number:
4.
000000000 (9 zeros).
You must attach a brief explanation when information is not available.
When there is not sufficient space on the claim form, number additional pages and attach them to the form
5.
with a paper clip.
DO NOT staple, tape, cross out or otherwise alter the form.
6.
A claim form that does not contain the filing party’s name and address, the deceased employee's name,
7.
the deceased employee's employer's name and address, date of accident or occupational disease, a
description of how the accidental injury or occupational disease occurred, or sufficient information to
process the claim may be rejected and returned to the filing party.
Sign and date the Claim for Funeral Benefits Only form.
8.
Attach a notarized Certification of Funeral Benefits form (WCC C-18). The Certification of Funeral
9.
Benefits form must: (1) be signed by the provider of funeral services or mortician; (2) include an
attached itemized statement of the services performed and corresponding costs; (3) be signed by
the person authorizing the burial or other services; (4) be notarized; and (5) include the name of the
deceased employee.
Mail the completed, signed form and attachments to the Workers' Compensation Commission at the
10.
address below.
FAILURE TO FOLLOW THESE INSTRUCTIONS MAY RESULT IN UNNECESSARY DELAY OR RETURN
FOR CORRECTION AND RESUBMISSION OF THE CLAIM FORM.
10 East Baltimore Street w Baltimore, Maryland 21202-1641
410-864-5100 w Email: info@wcc.state.md.us w Web:
MD WCC C19 (07/01/08)
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