Employee'S Claim Form

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EMPLOYEE’S CLAIM
WORKERS’ COMPENSATION COMMISSION
10 East Baltimore Street
CLAIM NUMBER:
Baltimore, Maryland 21202-16415
TOLL FREE 1-800-492-0479 Outside Baltimore
BALTIMORE PHONE 410-864-5100
BALTIMORE TTY FOR DEAF 410-383-7555
PERSONAL INFORMATION
4. Phone Number
3. Claimant Last Name
1. Claimant First Name
2. Middle Initial
5. Mailing Address
6. City
7. County
8. State
9. Zip Code
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
20. Employer Phone Number
19. Complete Address
21. City
22. State
23. Zip Code
26. Notice of Injury Given?
YES
25. Location where accident occurred
24. 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 regarding any work-related activity or return to work may subject you to fines, imprisonment or both and disqualify
you from receiving benefits. You MUST complete all required information (fields), "Submit" the data via the button on the form, sign the form and mail it to the
NOTE:
Commission at the address on the form. You may not alter or add information to the printed form. Failure to follow all instructions may result in a return of the form
in the processing or non-processing of your claim. Print a copy for your records and a copy to supply to your employer and/or their insurance carrier.
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
38. Attending Physician Name
39. Address
40. Apt. / Suite
41. City
42. State
43. Zip Code
44. If you were in a hospital – Hospital Name
45. Address
46. Apt. / Suite
47. City
48. State
49. Zip Code
58. If Health Insurance used, give name of Insurance Co.
_______________________________________________________________________________________________________________
I hereby make claim for compensation for an injury resulting in my disability due to an
accident (or disease) arising out of and in the course of my employment, and in support
Claimant Signature: __________________________________________
of it make the foregoing statement of facts. I hereby certify that the information I have
given is accurate and that I have read the information on this form.
Date: ______________________
READ 2nd PAGE BEFORE SIGNING. KEEP DUPLICATE COPY FOR YOUR RECORDS.
Email Address:
Received:
WCC Web Form C1 Page 1 of 2

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