Employer'S Questionnaire Template
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4EMPLOYER’S QUESTIONNAIRE
PAGE NUMBER: 1
CLAIMANTS NAME: ____________________________________________
WORKERS’ COMPENSATION COMMISSION CLAIM NUMBER: ___________________
State of Maryland, Uninsured Employers’ Fund, pursuant to Maryland Code LE 9-1002, hereby propounds the following
questions to the alleged Employer.
1.
State your full company name, address and telephone number. If you operate or trade under more than one
name, state each company name.
2.
Is your business incorporated: YES______ NO_______ If “yes”, state:
a)
Corporate Name.
b)
Date and State of Incorporation.
c)
Name, address and telephone number of the Resident Agent:
d)
Name of the officer or person responsible for the general management of the company in Maryland.
e)
Federal Identification Number.
3.
If you are not incorporated, state the following:
a)
Your full name, address, telephone number, social security number and date of birth.
b)
The name, address, phone number, date of birth, and social security number of all your partners in
the business.
4.
State what type of business your company is engaged in.
5.
Are you licensed to do business in Maryland? YES___________ NO_________. If yes, state the following:
a)
Type of license or permit, and date issued.
b)
Name and address of agency who issued license or permit.
MD WCC MD WCC H-38 5/05/06
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