Employer'S Questionnaire Template (Page 4 of 4) in pdf

Employer'S Questionnaire Template Page 4

PAGE NUMBER: 4

EMPLOYER’S QUESTIONNAIRE

CLAIM NUMBER: _______________

22. State the dates during which the claimant has been unable to work as a result of claimant’s injury. If claimant

has done any work since the date of injury, state who claimant worked for, the dates worked, what claimant did

and the income that claimant earned for such work.

23. Since the injury, has claimant filed for unemployment benefits? If yes, state when the claim was filed, the claim

number and the dates for which claimant received benefits.

24. Either before or since this injury, has claimant been involved in any accidents, injuries or serious illness or

disease? If so, provide details.

25. At the time of claimant’s injury, was the claimant intoxicated or under the influence of any medication or drugs?

26. If any third party was involved in the cla imant’s injury, state each name and address.

27. If claimant is alleging an occupational disease, state:

The first date that claimant was disabled from work.

The first date that claimant was treated.

The date when claimant gave you or your company notice of disability.

Was the claimant exposed to the occupational hazard as alleged in the claim?

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.

____________________________________________

EMPLOYER

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, 300 East Joppa Road, Suite 402, Towson, Maryland 21286, and all parties to this case on this

________ day of ________________________, 20____.

_____________________________________________

EMPLOYER OR ATTORNEY FOR EMPLOYER

MD WCC H-38 5/05/06

Employer'S Questionnaire Template Page 4