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

Wcc Form H-37 - Claimant Questionnaire - Maryland Uninsured Employers' Fund Page 4

PAGE NUMBER: 4

CLAIMANT’S QUESTIONNAIRE

CLAIM NUMBER: ______________

18)

If you have ever filed a workers’ compensation claim, lawsuit for an injury, Social Security claim, Veteran’s

claim or other disability claim, state the date filed, nature of injury or disability, claim number and where the

claim was filed. If the suit or claim resulted in a settlement, recovery or award, state the results.

19)

If in the past 15 years you have been convicted of a crime or moral turpitude or an infamous crime including,

but not limited to, a crime of theft or perjury, and at the time of your conviction you were over the age of

eighteen years and you were represented by counsel or waived your right to counsel, set forth the nature of the

conviction, criminal case number, and the date and location of the conviction.

20)

Was any third party involved in your accident? If so, state each party’s name, address and telephone number

and state whether you have made a claim against that party and state any amount recovered.

21)

If you are claiming an occupational disease, state:

a) The first date you were disabled from work.

b) The first date of treatment and who treated you.

c) When did you give notice of your disability to your employer?

d) When you were last exposed to the hazard and who were you working for when last exposed.

e) State all medical treatment as a result of your disease. Attach copies of all medical reports, records and

bills.

I HEREBY CERTIFY, under the penalties of perjury, that the information provided herein is true and accurate according to

the best of my information, knowledge and belief.

________________________________________

CLAIMANT

I HEREBY CERTIFY that the information provided herein was mailed, postage prepaid, to the Workers’ Compensation

Commission, 10 East Baltimore Street, Baltimore, Maryland 21202-1641, the Uninsured Employers’ Fund, Suite 402, 300

East Joppa Road, Towson, Maryland 21286, and all parties to

the case on this _______ day of

___________________________, 20____.

_________________________________________

CLAIMANT OR CLAIMANT’S ATTORNEY

WCC Form H-37 (Rev 08/15/07)

Wcc Form H-37 - Claimant Questionnaire - Maryland Uninsured Employers' Fund Page 4