This is the current Employee Claim Form that is required to submit your claim to the Commission.
Watch the instructional video linked below. Read and follow all instructions. Submit, print and sign the claim information page 1 and Authorization for Disclosure of Health Information page 2. Mail the completed, signed form (pages 1 and 2) to the MD WCC. You may not write on the form except for your signature and date where indicated. Page 3 contains general information and instructions.
The Online Employee Claim Form C-1 MUST be completed online - on your PC - using Formatta Filler. The form MAY NOT be printed blank and completed offline by hand or reused for another claim; such forms are returned. The completed/submitted form must be printed ON WHITE PAPER -via the SUBMIT button on page 1 of the form- 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 (within 10
business days) to file your claim.
You must include an email address where indicated on the form to receive a confirmation of your submission.
A brief, 6 minute video providing information
about the online Employee Claim Form, Formatta software and how to use
our online processes is available below. The video is Windows Media Format (*.WMV) and will play on your PC using Windows Media Player. You may pause and replay the video. The video is about 12MB and will load quickly with a broadband Internet connection.
|CLICK TO WATCH THE VIDEO|| ||CLICK to download a text version of the audio.|| ||
Was the video helpful? Please let us know.|
Please view the instructional video, read and/or PRINT ALL INSTRUCTIONS & INSTALL FORMATTA FILLER, then launch your fillable form.
Download the instructions that are included as page 3 of the Employee Claim form (PDF).
and "Run" Formatta Filler 7.0 software from this link
Formatta Filler version 7.0 for Windows is
required to submit your form.
Filler for Mac is discontinued by Formatta.
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 without processing.
If you do not provide a valid Social Security number on the form, you MUST enter 000-00-0000.
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
on page 1 and page 2. The signed form should be mailed as soon as possible.
Read, complete, sign and date the Authorization for Disclosure of Health Information. An incomplete claim form that does not include the signed Authorization for Disclosure of Health Information (page 2) will be rejected and returned to the claimant.
|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.|
The completed/submitted form must be printed on white paper via the SUBMIT button on the form, must display the date stamp at the bottom of the form, must be signed by the injured worker and must be mailed to the Commission in a timely fashion to file the claim. The SUBMIT button will submit data to the WCC and prompt to PRINT THE FORM, then SAVE THE FORM to your PC in a familiar place like "My Documents". Print the completed form on white paper when instructed, sign and mail it to the address indicated on the Employee Claim Form C-1 as soon as possible.
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. After the form is printed, you may not alter the form or write corrections on the form. If altered in any way, the form will be returned to you and your claim will not be filed. If you fail to send the signed form to the WCC, we will send you a notice that your signed Employee Claim Form C-1 has not been received and you claim is not filed.
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 data will be deleted and your claim WILL NOT BE FILED if you do not mail a properly completed and signed form to the WCC. 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. If you make a mistake on the form, don't mail the erroneous form to the WCC. You may complete/submit, sign and mail a form with the correct information or submit the WCC Form "Request for Document Correction", C90R from our FORMS page.
Enter a valid email address on the form, please enter "none" if you do not have an email address. This will send a confirmation receipt with the form ID number, date & time and additional information regarding your claim to the email address entered on the form.
All information (input) fields MUST be completed except the "treating physician" information, since the injured worker may not have received medical treatment prior to the completion of the Employee Claim Form C-1. Each input field will indicate via a "tip" or description window what information is needed for this field and if it is "Required".
An incomplete form without all required information will not submit. Be sure that you have entered all personal information, accident information and dates on the form. A submitted form will include a "time/date" stamp. If the form data does not successfully submit, the printed form will not be accepted by the WCC and will be returned.
You may not print the blank form from your PC to type or hand write on the Formatta form, such 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|