This is the Employee Claim Form required to
file your claim with the Commission.
Your claim is
not filed until you complete the form,
submit it online then print, sign and mail the form (pages
1 and 2) to the Commission.
Your claim filed
date is the date we have accepted and processed
the signed form.
Watch the video for step by step instructions
and real-time visuals.
The Online Employee Claim Form C-1 MUST be completed
and submitted online - on your PC - using
You must include your valid
email address on the form
DO NOT print a blank form to complete offline by hand or reuse
a saved form.
The completed/submitted form must be printed ON WHITE PAPER, must display the date stamp at the bottom of the form, must be signed where indicated on page 1 and page 2 by the injured worker and must be mailed to the Commission in a timely manner (
such as within 10
business days) to file your claim.
You may not alter the printed
form (no corrections or changes of any kind).
Altered forms are returned.
WATCH THE VIDEO HERE
Download a text version of the audio.
Was the video helpful? Please let us know.|
and "Run" Formatta Filler software from this link
Formatta Filler version 7.x or later for Windows is
required to submit your form. Google
Chrome does not properly use Formatta Filler;
Internet Explorer or Mozilla Firefox will work with
Select "RUN" when prompted to download the "fillersetup.exe" and follow the on screen installation instructions. If using a business/corporate PC, you MUST have permission/rights to install software on your PC. If you do not have this permission to install l software on your PC, please "Save" (to a familiar location on the PC) instead of "Run" and contact your IT support to install the software for you.
After a successful installation, Formatta Filler will launch and display the Formatta logo.
Forms that are handwritten, typed or altered
are not accepted and are returned.
If you do not provide a valid Social Security number on the form, you MUST enter 000-00-0000
on the form.
Invalid numbers (such as 999-99-9999, 666-66-6666) are not accepted.
When information is unknown or not available,
zeros should be entered in required numeric
fields. For example, Gross Wages should be
entered as all zeros (00).
Submit only one claim form, filing duplicates
will delay claim processing.
Confirm your claim filing via the Public Claim Data Inquiry located in the PUBLIC ONLINE SERVICES menu about
a week (5-7 business days)
after you have mailed the completed, signed form to the Commission or after you receive
the Notice of Claim in the mail.
The Notice is mailed to you and all parties when your claim has been accepted and processed.
Weekends and holidays will
affect processing time.
All claim forms submitted to the Commission MUST be signed personally by the injured worker, by an individual who has the injured worker's Power of Attorney or status as their Legal Guardian. The signed form should be mailed as soon as possible.
You must read, sign and date the Authorization for Disclosure of Health Information. A claim form that does not include the signed Authorization for Disclosure of Health Information (page 2)
is rejected and returned.
|PLEASE thoroughly read and follow all instructions before accessing the C-1 WebForm. If necessary, please print these Instructions before you complete the form. In order to utilize WCC WebForms to securely submit online to the WCC, you must install Formatta Filler software on your PC. Formatta Filler is much like Adobe® Reader. Formatta Filler is designed for Microsoft Windows (and Mac OS X v10.3) and Internet Explorer 6.x or later version is recommended to properly function. Formatta Filler is designed to securely and safely submit personal data via the Internet. It uses high level encryption and security technologies preventing anyone except the submitting person and the authorized recipient to view/open the form. Please read all instructions prior to beginning to install Formatta Filler. Questions about Formatta Filler are addressed via the "Data Sheet" link above.|
Maryland Law requires that an Employee Claim Form C-1 signed by the injured worker be sent (mailed/delivered) to the Workers' Compensation Commission to file a claim.
If you fail to send your signed form to the WCC within 10 days, you will receive a notice from the WCC stating that your submitted
claim will be deleted and your claim IS NOT FILED. If you do not respond as instructed on the Notice, your claim information will be deleted, your claim will NOT be filed.
Be sure that all of the information entered on the form is correct BEFORE you SUBMIT the form data.
required form fields MUST be completed. A form without all required information will not submit. Be sure that you have entered all personal information, accident information and dates on the form.
When submitted the form will include a "time/date" stamp.
You may not print the blank form from your PC to type or hand write on the Formatta form;
if you do the form will be returned to without processing your claim. If you cannot complete the online Employee Claim Form C-1, please request that the paper form be mailed to you.
Click here for information on the paper version of the Employee Claim Form C-1.
WCC COUNTY CODES TO COMPLETE THE CLAIM FORM
Allegany - AL
Charles - CH
Prince George's - PG
Anne Arundel - AA
Dorchester - DR
Queen Anne's - QA
Baltimore - BA
Frederick - FR
Saint Mary's - SM
Baltimore City - BC
Garrett - GA
Somerset - SO
Calvert - CT
Harford - HA
Talbot - TA
Caroline - CA
Howard - HO
Washington - WA
Carroll - CL
Kent - KT
Wicomico - WI
Cecil - CE
Montgomery - MT
Worcester - WO
|Out of State (outside Maryland) - OS|