Wcc Form H-37 - Claimant Questionnaire - Maryland Uninsured Employers' Fund (Page 2 of 4) in pdf

Wcc Form H-37 - Claimant Questionnaire - Maryland Uninsured Employers' Fund Page 2

PAGE NUMBER: 2

CLAIMANT’S QUESTIONNAIRE

CLAIM NUMBER: _____________

Regarding your job at the time of your injury:

a. Did you set your own work hours? If not, who set them?

b. How many hours per week did you work?

Were you paid by the job or by the hour?

Were you paid by check or cash?

f. Did your employer withhold taxes and social security from your pay?

At the time of your injury, what were your earnings per week? Did you file tax returns for both the year of and

the year before your injury? To verify your employment and earnings, attach copies of your pay stubs or

payroll records for the 13 weeks prior to your injury. If such records are unavailable, attach copies of your tax

returns for both the year of and the year before your injury.

Describe your accident and identify the parts of your body injured. State the date, time and place of your

accident.

State the names, addresses and telephone numbers of all witnesses to your accident and injuries.

State the name of all persons with whom you reported or discussed your accident and injuries.

10)

State the name and address of any person who has or may have personal knowledge of facts relating to your

accident or injuries.

Wcc Form H-37 - Claimant Questionnaire - Maryland Uninsured Employers' Fund Page 2