Wcc Form H-37 - Claimant Questionnaire - Maryland Uninsured Employers' Fund (Page 3 of 4) in pdf

Wcc Form H-37 - Claimant Questionnaire - Maryland Uninsured Employers' Fund Page 3

PAGE NUMBER: 3

CLAIMANT’S QUESTIONNAIRE

CLAIM NUMBER: _____________

11)

If your injury involved a vehicle:

a) State who owned the vehicle and whether you leased the vehicle. If there was a signed lease agreement,

attach a copy.

b) Was a police report made; if so, attach a copy.

c) State the locations where the trip started and the destination.

12)

During the 48 hours prior to your injury, had you consumed any alcohol or taken any intoxicating drugs or

medications? If so, state the substance that you took and the time that you took it.

13)

State the names and addresses of all doctors, hospitals and any other medical providers who have examined or

treated you for this injury. Attach a copy of all records, reports and bills.

14)

If your employer or any health insurance company has paid for your medical treatment, lost time or disability,

state who has made such payments. If you have filed a claim against a private insurance company or anyone

else for this injury, state who you filed against and when.

15)

State the dates on which you have been unable to work as a result of your injury. Attach copies of all medical

off-work slips. If you have done any work since the date of your injury, state who you worked for, the dates

you worked, what you did, and the income that you earned for your work.

16)

Since your injury, have you filed for unemployment benefits? If yes, state when you filed, the claim number

and the dates for which you received benefits.

17)

Either before or since this injury, if you have had any accidents, injuries or serious illness, which may affect the

injury and/or disability claimed in this claim, state when and how it occurred, the part of the body injured or

affected, and state the names and addresses of all doctors, hospitals and any others who treated you which may

affect the injury or disability of this claim.

Wcc Form H-37 - Claimant Questionnaire - Maryland Uninsured Employers' Fund Page 3