Wcc Form H-37 - Claimant Questionnaire - Maryland Uninsured Employers' Fund printable pdf download

Wcc Form H-37 - Claimant Questionnaire - Maryland Uninsured Employers' Fund

PAGE NUMBER: 1

CLAIMANT’S QUESTIONNAIRE

CLAIMANT’S NAME:

WORKERS’ COMPENSATION CLAIM NUMBER:

State of Maryland, Uninsured Employers’ Fund, pursuant to Maryland Code LE 9-1002, hereby propounds the following

questions to the Claimant.

BE ADVISED THAT THE WORKERS’ COMPENSATION COMMISSION WILL NOT CONDUCT A HEARING

ON YOUR CLAIM UNTIL YOU HAVE COMPLETED AND FILED THIS QUESTIONNAIRE.

State your full name, address, telephone number, social security number and date of birth.

State the full name, address and telephone number of your employer at the time of your injury.

3a)

Were other companies involved in the project or jobsite on which you were injured? If yes, state each company

name, address and telephone number and specify the address where the accident occurred.

3b)

Specify the address where the accident occurred.

Regarding your job at the time of your injury:

What was your job title?

b. What were your job duties?

Who hired you?

d. When were you hired?

Did you sign any contracts with your employer? If so, attach a copy.

f. Who was your foreman or supervisor?

Wcc Form H-37 - Claimant Questionnaire - Maryland Uninsured Employers' Fund