Free Microsoft Word - TT_c06.DOC - Maryland

WORKERS' COMPENSATION COMMISSION

INSURER'S TERMINATION OF TEMPORARY TOTAL DISABILITY BENEFITS
Pursuant to LE §9-733(b), Annotated Code of Maryland, this form must be sent to the claimant. A copy must also be sent to the Workers' Compensation Commission and claimant's attorney.

WCC Claim Number Claimant Employer Insurer

Social Security Number

This is your last temporary total disability compensation check/payment and includes (date). benefits through: The insurer/employer has terminated your payments for the following reason(s): 1. You returned to work on . (date)
. (date)

2. There is no medical evidence or documentation to support continuing payment. 3. You failed to keep the medical appointment scheduled for 4. You have reached maximum medical improvement. 5.
Contact
Insurer Representative

.
at ( )
Telephone

for further information if desired. After contacting the insurance representative, if you are in disagreement or are dissatisfied, you have the right to request a hearing before the Workers' Compensation Commission. Please include a copy of this form with your request for a hearing on the MD WCC "Issues" form (H24R) selecting the appropriate Temporary Total Disability issue (#13 or #17).

INSURER CERTIFICATION OF SERVICE
I hereby certify that a copy of this form has been filed with the Workers' Compensation Commission and sent to all parties and/or their attorneys. Signature Name Telephone Number Date

10 East Baltimore Street Baltimore, Maryland 21202-1641 410-864-5100 Email: [email protected] Web: http://www.wcc.state.md.us
WCC Form C-06 (02/15/07)