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Maryland Form Center -

Type & Print Forms - programmed for direct type and print functionality.

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Form

Description

MD_FROI.pdf First Report of Injury or Illness - http://www.wcc.state.md.us/WFMS/Med_WebForms.html
FROI_Print.pdf First Report of Injury or Illness - This form is ONLY for internal use. DO NOT file this form with the state. You must use the form provided by the state (above).
H24R.pdf Issues Form - required with Forms H26R, H30R
C24R.pdf Request to Enter Appearance of Counsel
C26R.pdf Request to Enter Appearance of Counsel for Employer / Insurer
C25R.pdf Request to Strike Appearance of Counsel
C2.pdf Statement of Wage Information
H25R.pdf Request for Action on Filed Issues
H28R.pdf Request for Continuance or Postponement of Hearing
H26R.pdf Request for Emergency Hearing
H29R.pdf Request for Postponement of Emergency Hearing
C90R.pdf Request for Document Correction
H50.pdf Request for Transcript
H27R.pdf Request for Rehearing
H30R.pdf Request for Reconsideration/Modification
H33R.pdf Request to Implead a Party
H32R.pdf Request to Implead a Party in Uninsured Employer's Fund
H12.pdf Request for a Hearing on Previously Withdrawn Issues
C06.pdf Insurers Termination of Temporary Total Disability Benefits
H37.pdf Claimants Questionnaire
H38.pdf Uninsured Employer Employer Questionnaire
H10.pdf Application for Lump Sum
eC50R.pdf Stipulation for Advancement
C3.pdf Claim Amendment
c10.pdf Insurer's Termination of Medical Benefits
H11.pdf Cover Sheet for Action on Claims on Appeal
C35.pdf Dependents Claim for Death Benefits
C18.pdf Certification of Funeral Expenses
C19.pdf Claim for Funeral Benefits Only
H44.pdf Claimant's Consent to Pay Attorney and Doctor Fees
H34.pdf Stipulation of Parties and Award of Compensation
H07.pdf Settlement Worksheet
H05.pdf Claimants Affidavit in Support of Settlement
A25.pdf Authorization for Release of Medical Information
C24.pdf POSTER - Notice for Employees Poster - MUST be printed on 8.5" X 14" (legal size) goldenrod or yellow paper.
h13r.pdf Insurer Request for Change of Address
esubpoena.pdf Subpoena/Subpoena Duces Tecum
ho8-noi.pdf Notice of Intent to Subpoena Medical Records and Certificate of Service
h08-ots.pdf Objection to Subpoena of Medical Records
H22R.pdf Employer/Insurer Request for Change of Address
H31R.pdf Claimant Request for Change of Address
h23r.pdf Request for Employer Designee to Receive Notice of Employee Claims
H35R.pdf Request for a Hearing for Referral to Maryland Insurance Fraud Division
C51.pdf Claim for Medical Services
H32.pdf Controversion of Medical Claim
VR1.pdf Proposed Rehabilitation Plan
VR2.pdf Vocational Rehabilitation Closure Report (Filed Online Only)
VR6.pdf Agreement on the Propriety of Services and Selection of Practitioner
VR13.pdf Disagreement with Proposed Vocational Rehabilitation Plan
IC-02.pdf Sole Proprietor Status as a Covered Employee Form
IC-03.pdf Joint Election Form
C15R.pdf Inclusion Form
IC16.pdf Exclusion Form
A05.pdf Application for Self-Insurance and Instructions
A05s.pdf Self-Insured Employers Application to Add a Subsidiary Form A-05S
A04.pdf Parental Guarantee and Board Resolution
A07.pdf Continuous Surety Bond Form
A08.pdf Irrevocable Letter of Credit
A09.pdf Memorandum of Understanding Form
IC_1.pdf Insurance Information Report
IC_1_addl.pdf Additional Payroll Offices
IC_1_inst.pdf IC-1 Information Report Instructions
attyreg.pdf Attorney Registration/Change Form
Employee Claim Form - Claimant must use original C1 form here:
http://www.wcc.state.md.us/WFMS/C1_WebForms.html
FRS.pdf Financial Reporting System Selected Data from Audited Financial Statements
settle.pdf Agreement of Final Compromise and Settlement
VR7.pdf Initial Rehabilitation Services Referral Form (Filed Online only)
VR10.pdf Rehabilitation Service Plan
SF2.pdf Surgeon's Report
qanda_ee.pdf BROCHURE - Q & A for Employees about Maryland Workers' Compensation Law
qanda_emplr.pdf BROCHURE - Q & A for Employers about Maryland Workers' Compensation Law