Employee'S Claim Form - Workers' Compensation Commission, Maryland
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3EMPLOYEE’S CLAIM
WORKERS’ COMPENSATION COMMISSION
10 East Baltimore Street
CLAIM NUMBER:
Baltimore, Maryland 21202-1641
BALTIMORE PHONE 410-864-5100
TOLL FREE 1-800-492-0479 IN MARYLAND
TTY USERS CALL VIA MARYLAND RELAY
PERSONAL INFORMATION
4. Phone Number
3. Claimant Last Name
1. Claimant First Name
2. Middle Initial
( )
-
5. Street Address
6. City
7. County
8. State
9. Zip Code
MD
10. Social Security Number
11. Sex
12. Date of Birth
13. Marital Status
14. Gross Wages Per Week
15. Paid full wages for day?
YES
M
M
- -
/ /
$
.
NO
F
S
16. What Is Your Regular Work?
17. What Was Your Work When Injured?
EMPLOYER INFORMATION
18. Full and correct business name of your employer
19. Employer Phone Number
( )
-
20. Complete Address
21. City
22. State
23. Zip Code
24. Notice of Injury Given?
MD
YES
26. Location where accident occurred
25. Nature of Employer’s business
NO
AM
PM
27. Whom did you notify of the accident?
28. First Day Not Worked
30. Date of accident/occupational
29. Occupational Disease?
disease disablement
/ /
YES
/ /
Time
NO
31. Describe how accidental injury occurred
32. Describe how occupational disease occurred
OR
Failure to disclose information or giving false information, including information regarding any work related activity or return to work either before or after an award of benefits,
may subject you to fines, imprisonment, or both, and disqualify you from receiving benefits. A CLAIMANT’S FAILURE TO COMPLETE THIS FORM IN COMPLIANCE WITH THE
NOTE:
DIRECTIONS ON PAGE 3 MAY RESULT IN THE CLAIM BEING REJECTED. TO EXPEDITE YOUR CLAIM, YOU MAY SEND A COPY OF THE COMPLETED FORM TO YOUR
EMPLOYER.
CLAIM INFORMATION
33. What member of your body was injured?
34. Amputation required?
35. Employer requested to provide medical care?
36. Medical care provided?
37. Date returned to Work
YES
YES
YES
NO
NO
NO
/ /
39. Street Address
40. Apt. / Suite
38. Attending Physician Name
41. City
42. State
43. Zip Code
MD
44. If you were in a hospital – Hospital Name
45. Street Address
46. Apt. / Suite
47. City
48. State
49. Zip Code
50. If Health Insurance used, give name of Insurance Co.
MD
_______________________________________________________________________________________________________________
I hereby make claim for compensation for an injury resulting in my disability due to an accident
SIGNATURE: __________________________________________
(or disease) arising out of and in the course of my employment, and in support of it make the
foregoing statement of facts. I hereby certify that the information I have given is accurate and
DATE: ______________________
that I have read the information on this form.
Email Address:
Received:
WCC Web Form C1 Page 1 of 3
*E10108475*
*E10108475*
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