Free Microsoft Word - LUMP SUM _H-10_.DOC - Maryland

WORKERS' COMPENSATION COMMISSION

APPLICATION FOR LUMP SUM
INSTRUCTIONS: This form is to be used ONLY for requesting a lump sum payment from a permanent disability award. CLAIM NUMBER:
EMPLOYER:

CLAIMANT'S NAME:

INSURER: AGE MARITAL STATUS With/For whom? Social Security Number Accident/Occupational Disease Date # of Dependents

Are you working? No

What are you making per week? How much do you want in a lump sum?

Reason (Complete & detailed explanation) Continue as attachment if needed

375 Characters

NOTE: All bills, papers, etc. in support of this request must be attached to this application before it can be considered for approval by the Commission. Employer/Insurer Consents to the Lump Sum Employer/Insurer Objects, Please Set for Hearing SIF Consents to the Lump Sum SIF Objects, Please Set for Hearing

I hereby certify that a copy of this request and its documentation has been sent to opposing counsel/parties.
REQUESTED BY: Full Name CLAIMANT CLAIMANT'S ATTY Signature EMPLOYER INSURER/EMPLOYER ATTY Date of Request OTHER:

STREET ADDREESS

TELEPHONE

CITY

STATE

ZIP CODE

CLICK HERE TO CLEAR THE FORM
WCC H-10 (Rev. 9/03/03)

10 East Baltimore Street q Baltimore, Maryland 21202-1641 410-864-5100 q Email: [email protected] qWeb: http://www.wcc.state.md.us