Free Siptulation of Parties and Award of Compensation H-34 - Maryland

WORKERS' COMPENSATION COMMISSION
10 East Baltimore Street G Baltimore, Maryland 21202-1641 410-864-5100 q Email: [email protected] Web: http://www.wcc.state.md.us

STIPULATION OF PARTIES AND AWARD OF COMPENSATION
WCC Claim #: Claimant: Claimant SS #: Employer: Insurer:
by and between , EMPLOYER, and , INSURER, that an Award of

It is STIPULATED this EMPLOYEE, and

day of

, 20

Compensation is necessary and appropriate in the above-titled claim based on the following information: (1) Date of Accident: (2) Employee's Average Weekly Wage: (3) Temporary Total / Temporary Partial: [Amended: Y Y N] N]

$

[Amended:

(4) Attached hereto are the medical evaluation report(s) of: Claimant's Doctor #1 Insurer's Doctor #1 #2 #2

(5) The Parties agree to a permanent partial disability of :

at the rate of $

, payable weekly, beginning

for

weeks.

IN WITNESS WHEREOF, the Parties hereto have duly executed the aforementioned statements on the day and year as stated above. ATTEST:

Signature of Attorney for Claimant

Signature of Claimant

, EMPLOYER and
INSURER

BY: Page 1 of 2 Pages Signature for Employer/Insurer

WCC H-34 (Rev 9/05/03)

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STIPULATION OF PARTIES AND AWARD OF COMPENSATION
Page 2 of 2 Pages



The Employee being unrepresented by Counsel, the Insurer furnishes herewith copies of all medical reports in its possession. The undersigned, as Employee in the above-entitled case and not being represented by Counsel, does hereby state that I understand that this Stipulation does not foreclose my future right to reopen my case and the right to continuing medical care; that I have the right to have any future claim heard before the Workers' Compensation Commission; and that I would have a right to appeal any decision in the future to be made by the Workers' Compensation Commission; and that I have entered into this Stipulation only for the purpose of determining the degree of my disability at this time.

WITNESS:

____________________________ CLAIMANT: ____________________________
Signature Signature

************************************************************************************

(6) COUNSEL AND MEDICAL FEES: Counsel for Claimant in this case requests that from the final weeks of compensation the following fees shall be paid:

CONSENT OF CLAIMANT: The Claimant in this case has read and signed the Stipulation and consents to the fees as set forth above.

Signature of Claimant ***********************************************************************************

Page 2 of 2 Pages

WCC H-34 (Rev 9/05/03)

CLICK HERE TO CLEAR THE FORM