Form C-1 Employee Claim
- Used to file employee’s claim
- Notice of claim filed will be issued by the Commission and will include a claim number
Form C-24 Employer’s Posting Notice
- Maryland Law requires employers to post notice that the employer has secured workers’ compensation insurance coverage
Form SF-1 First Report of Injury (Employer’s FROI Form IAIABC 1A-1)
- Filed by employer (or insurer) upon notice by employee of accidental injury or occupational disease
- Includes details of accident and injury
Hearings
A hearing notice includes the following information:
- All parties in the Workers’ Compensation Commission’s claim data;
- Date, time, location of hearing
- When a case is set on a special issue
Form H-24R Issues Form
- Used to request or initiate a Hearing after the Consideration date
- Must specify issues to be resolved
Form C-2 Statement of Wage Information
- Needs to be submitted before consideration date or to update wage information
Form H-25R Request for Action on Filed Issues
- Requests include: withdrawal of issues previously filed (filing party only), dismissal of claim (on behalf of claimant only), “set with” scheduling to schedule claims together at hearing, and change of venue.
- Requests can be made by claimant, employer/insurer, either party’s attorneys, or SIF/UEF
Form C-24R Request to Enter Appearance of Counsel
- Used by attorney to enter his/her appearance on behalf of a claimant.
- Attorneys entering appearance on behalf of an employer or insurer use Form C26R
Form C-25R Request to Strike Appearance of Counsel
- Claimant may request that his/her Counsel not appear on claimant’s behalf
Form H-28R Request for Continuance of Hearing
- Must include reason for requested continuance
- May be filed by any party
Form H-26R Request for Emergency Hearing
- Form must be accompanied by Issues Form H-24R
- Must include justification for emergency hearing
Form H-29R Request for Postponement of Emergency Hearing
- This form is used by parties to the compensation claim to request continuance or postponement of a hearing
Form C-90R Request for Document Correction
- Must include a description of the error and the correction requested
- This form is used by a party only to notify the Commission that an undisputed factual error exists in a document that has been filed in a workers’ compensation claim
- If the discrepancy is a factual dispute between the parties, it should be resolved at the hearing.
Form H-27R Request for Rehearing
- This form is used by parties to a compensation claim only to request consideration of a prior decision of the Commission.
- Request for Rehearing must be based on alleged error of law or a mistake of fact and must be filed within 15 days after the decision.
- The request must include a justification for rehearing.
Form H-30R Request for Modification
- This form is used by parties to a compensation claim to request that an Order be reconsidered, reopened, or modified.
- Modification can be sought as to whether the claimant’s permanent disability has increased or decreased or if the claimant is entitled to additional temporary total benefits.
- This form must be accompanied by Issues Form H-24R
Form H-33R Request to Implead a Party
- This form is used to implead additional parties in a claim.
Form H-32 Controversion of Medical Claim
- This form is used ONLY to controvert an Order Nisi and MAY not raise any other issue.
- A hearing will be scheduled on this controversion in the normal course.
Form H-12 Request for a Hearing on Previously Withdrawn Issues
- This form is used by parties to a compensation claim to request a hearing on issues filed and withdrawn within the past 90 days.
- Issues Form H-24R must be attached to this form.
Form C-06 Insurer’s Termination of Temporary Total Disability Benefits
- Employer/insurer must send this form to the claimant, the Workers’ Compensation Commission, and claimant’s attorney upon making the last temporary total disability compensation payment.
- If there is a disagreement, claimant may request a hearing using Issues Form H-24R.
Form H-37 Uninsured Employer – Claimant Questionnaire
Form H-38 Uninsured Employer – Employer Questionnaire
Form H-10 Application for Lump Sum
- The purpose of this form is to request a lump sum payment from a permanent disability award.
Form C-50R Stipulation for Advancement
- This form documents an advance agreed upon by all parties in a compensation claim.
Form C-3 Claim Amendment
- This form is used by a claimant to amend a claim and add or delete a body part at issue in an existent claim.
Form H-11-AOA Cover Sheet for Action on Claims on Appeal
- This form must be accompanied by a True Test copy of the Appellate Court’s Order and Case Docket Entry
Death Claims
Form C-35 Dependent’s Claim for Death Benefits
- Claimant must attach:
- A certified copy of the death certificate for the deceased employee;
- A certified copy of the certificate of the marriage certificate for the dependent and deceased employee, if the dependent is the surviving spouse of the employee; and
- A certified copy of the certificate of birth for the dependent, if the dependent is the surviving child of the deceased employee.
Form C-18 Certification of Funeral Benefits
- If making a claim for funeral benefits, this form must:
- Be signed by the provider of funeral services or mortician;
- Include an attached itemized statement of the services performed and costs incurred;
- Be signed by the person authorizing the burial or other services;
- Include the name of the deceased employee.
Form C-19 Claim for Funeral Benefits Only
- If there are no dependents and a party wishes to file a claim for funeral benefits only, this form must be completed and filed with a Form C18 Certification of Funeral Expenses attached.
Address or Information Changes
Form H-31R Claimant’s Request for Change of Address
- Claimant or attorney wishing to change Claimant’s address must submit the change for each claim
Form H-22R Employer or Self-Insured Employer Request for Change of Address
- This form is used to change the address of an employer or self-insured employer to change all claims registered with the Commission at the prior address shown below and may not be used to change an address in an individual claim.
Form H-13R Insurer Request for Change of Address
- This form is used to change the address of an insurer for all claims registered with the Commission at the prior address. This form cannot be used to change an address in an individual claim.
Form H-23R Request for Employer Designee to Receive Notice of Employee Claims
- Designee for employer submits a listing all of the employers to change the mailing address for all of your claims for your registered employers only.
Other Filing
Form H-35R Request for a Hearing for Referral to Maryland Insurance Fraud Division
- The Commission will refer the case to the Insurance Fraud Division of the Maryland Insurance Administration if, after a hearing, the Commission finds that the party requesting the referral has carried the burden of establishing by a preponderance of the evidence that the named person knowingly affected or knowingly attempted to affect the payment of compensation by means of a fraudulent representation.
- This form may be filed by any party at any time.
Form C-51 Claim for Medical Services
- This form is used to submit a claim for unpaid medical services
- If the claim includes multiple dates of service, indicate on an accompanying CMS 1500 form the amounts of any payments you have received and include a copy of the relevant EOB, Explanation of Benefits, Form.
- All relevant correspondence must be attached.
Form VR-6 Agreement on the Propriety of Services and Selection of Practitioner
- Attorneys and Insurers may file this form to affirm that they agree to the treatments and opinions of vocational rehabilitation services and the selection of the practitioner.
- The practitioner may not contact the claimant or initiate rehabilitation services until the practitioner receives a copy of this notice.
Subpoena & Medical Release
Form H-08 Subpoena/Subpoena Duces Tecum
- If the Subpoena is for Medical Records, the requesting party must attach a Form H-08/NOI Notice of Intent to Subpoena Medical Records.
- The requesting party will send this form and a copy to WCC. Once they issue the subpoena, the WCC will return the original to the requesting party, who must complete a new Form H-08/NOI and include a copy of it when mailing the subpoena to the other party and their counsel.
Form H-08/OTS Objection to Subpoena of Medical Records
- If claimant objects to the disclosure of medical records, he/she must file this form with the Workers’ Compensation Commission within thirty days from the date the Form H-08/NOI is mailed.
- If no objection (Form H-08/OTS)has been filed 30 days after the mailing date has passed, the requesting party will complete .
Settlement
Form H-44 Claimant’s Consent to Pay Attorney and Doctor Fees
- This form documents a claimants consent to pay attorney and doctor fees and provides an itemized list of all fees and costs.
- Copies of receipts and medical bills must be attached to this form.
Form H-34 Stipulation of Parties and Award of Compensation
Form H-07 Settlement Worksheet
- A claimant, or claimant’s attorney can use submit this worksheet to aid the Commission in approving the proposed Agreement of Final Compromise and Settlement.
Form H-05 Claimant’s Affidavit in Support of Settlement
- Claimant uses this form to ask the Workers’ Compensation Commission to approve the settlement of his/her claim.
- This is a required document for submitted settlements.
(Rated: 5.00
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