Free WORKERS' COMPENSATION COMMISSION - Maryland

WORKERS' COMPENSATION COMMISSION

CLAIMANT REQUEST FOR CHANGE OF ADDRESS
This form is to be used only to change the address of a claimant. Attorneys must use the WCC Attorney Registration Form to change any contact information.

WCC CLAIM NUMBER: CLAIMANT: EMPLOYER: INSURER: NEW ADDRESS

Street

Additional Info (Apt., Suite, etc.)

City

State

Zip Code

PRIOR ADDRESS

Street

Additional Info (Apt., Suite, etc.)

City

State

Zip Code

REQUESTED BY:

CLAIMANT

CLAIMANT'S ATTORNEY

FULL NAME

Street Address City State Zip Code

A copy of this form has been sent to the other parties/attorneys to this action.

__________________________________
SIGNATURE

DATE

TELEPHONE NUMBER

CLICK HERE TO CLEAR THE FORM
WCC H31R (03/22/04)

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