Free MD WCC Stipulation for Advancemen - Maryland


File Size: 49.7 kB
Pages: 1
File Format: PDF
State: Maryland
Category: Workers Compensation
Author: MD WCC Webmaster
Word Count: 112 Words, 764 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.wcc.state.md.us/PDF/PDF_Forms/eC50R.pdf

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WORKERS' COMPENSATION COMMISSION 10 EAST BALTIMORE STREET BALTIMORE, MARYLAND 21202-1641

STIPULATION FOR ADVANCEMENT
Instructions: This form is to be used only to document an advance agreed upon by all parties.

Claimant

WCC Claim Number
Employer Insurer

Social Security Number:

STIPULATION FOR ADVANCE
It is hereby stipulated between the parties that the Employer/Insurer will advance the Claimant the sum of $ compensation benefits. to be credited against any future

Employer/Insurer (Signature)
Date

Printed Name

Attorney for Claimant (Signature)
Date

Printed Name

Claimant Signature
Date

The above agreement is approved by the Workers' Compensation Commission this day of ,2 .

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Commissioner
WCC Form C50R (Rev. 9/2006)