|
|
 |
Forms cannot be filed
by email/attachment,
FAX or file sharing
platform. If you are not a
registered CompHub subscriber,
limited forms are available for
hardcopy filing. Only original forms
with original signatures
are accepted.
Please consider registration for
CompHub to access current claim
information, filing forms and more.
Forms
submitted must be current and as
provided by the Commission.
Altered, created/unauthorized or
obsolete forms are not accepted.
|
-
The injured worker can
file their claim
online
via CompHub - Employee Claim C-1.
-
The injured worker may also
request a paper (hardcopy) form to
be mailed to their street address
via this link - info@wcc.state.md.us
-
The
Employer
Designation form is
available here.
The
Employer or the Carrier should use
the
EMPLOYER SUBSCRIBER DESIGNATION form
to serve as written authorization
and request to the Commission for
the individual to be assigned for
the Employer in CompHub. The
Employer or the Carrier understands
and agrees that this assignment will
enable the Employer Subscriber to
establish a generic email address to
which all mail from the Commission
(e-notices, awards, etc.) will be
directed and will permit the
Employer Subscriber to assign
Employer Delegates, enabling access
to and for filing ability in all the
employer’s Maryland claims.
|
Select a link category
from the choices below to navigate to
available forms. |
|
Address/Information Change Forms |
Insurance, Compliance & Reporting |
|
Settlement Related Forms
(this page) |
Subpoena & Medical/Release |
|
Claims for Death Benefits |
Requests for
Hearing Transcripts |
|
Voc Rehab forms
not
in CompHub |
|
| |
|
The Employer's First Report of Injury
(FROI/SF1) IAIABC 1A-1
Filed by the employer or their
workers' compensation insurance
carrier via our
CompHub portal
if registered.
The
injured worker will file the Employee Claim Form C-1.A First
Report of Injury (FROI) must be
filed by the employer/insurer with the Workers' Compensation
Commission. In accordance with COMAR 14.09.01.02 ' Commission Forms, the
Commission only accepts the FROI form prepared by and issued by the
Commission, form IA-1 (r 1-1-02).
The
fields: Type of Injury/Illness, Date of Death (if applicable) and
Initial Treatment must be completed and are required by Maryland Occupational
Safety and Health (MOSH), a unit of the Division of Labor &
Industry. If these and
all other required fields are not complete or on a form other than
the Commission's, the FROI will be returned. Please see the complete
list of acceptable WCIO Type of Injury/Illness codes
|
|
|
HEARINGS -
the forms below may only
be used by claimants or employers who are not CompHub
subscribers.
DEPENDENT CLAIM FOR DEATH BENEFITS
and
Funeral Benefits
Please use CompHub
Effective October 1, 2011
Labor and Employment Articles,
9-683.1 through 9-683.5,
Annotated Code of Maryland (House Bill 417
- 2011 legislative
session) change benefits
provisions when a claim for
death benefits is filed with the
Workers' Compensation
Commission.
Note: Certain public safety employees
subject to the statutory
presumption set forth in 9-503
are exempt from the death
benefits provisions of Labor and
Employment Article, 9-683.1
through 9-683.5, Annotated Code
of Maryland. A county or
municipal corporation may elect
for the death benefits
provisions of Labor and
Employment Article, 9-683.1
through 9-683.5, Annotated Code
of Maryland, to apply to its
public safety employees subject
to the statutory presumption set
forth in 9-503.
Employers -
Go to
the
Dependent Claim for Death Benefits County & Incorporated
Municipalities page for information specific to those
employers who have the option to permanently opt-in to the new
benefits provisions.
The forms below are available on our
CompHub portal.
Certification of Funeral Expenses
Claim for Funeral Benefits Only
|
|
SETTLEMENT
-
Please see CompHub |
|
Medicare Set-Aside information PDF
|
|
| |
SUBPOENA & Medical Release
-
Please use CompHub |
BACK TO TOP OF THIS PAGE |
|
|
| |
ADDRESS OR INFORMATION CHANGE -
Please use CompHub |
|
Attorneys will update or change
their contact information via their
CompHub User Profile page.
| |
Miscellaneous, Other & Statutory Filing
Back to top |
|
|
| |
|
| |
| |
|
