WORKERS' COMPENSATION COMMISSION
10 EAST BALTIMORE STREET, BALTIMORE, MD 21202-1641
410-864-5100 Email: [email protected] Web: http://www.wcc.state.md.us
Claim Number: Claimant: Employer: Insurer:
THIS WORKSHEET to be made part of proposed Agreement of Final Compromise and Settlement: WHEREAS the undersigned, Claimant or Claimant's attorney avers as follows:
1. Is the claim contested as to compensability and/or causation? 2. Is further medical treatment for the injury recommended? -IF YES, does the Claimant have health care coverage for the recommended treatment? 3. Is there any potential S. I. F. liability in this case? 4. Is the Claimant working? 5. Is the claimant currently receiving: a) Social Security Disability Benefits? b) Medicare Benefits? 6. Is a third party claim involved in this case? -IF YES, attach required document per Rule .19B 7. Is the claim on appeal? 8. Is there a hearing pending on this claim? -IF YES, When? 9. Are the proceeds of this settlement to be payable 10. All pertinent medical reports are 11. Comments: attached OR weekly Yes Yes No No
Yes Yes Yes Yes Yes Yes Yes Yes
No No No No No No No No
or in a lump sum?
There are no medicals in this case.
Signature of Claimant
Signature of Claimant's Attorney Claimant's Attorney Name:
Attach only relevant Medical Information
Street Suite, Etc. City, State, Zip Code Telephone Number:
WCC Form H-07 (Rev 01/06)
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