Free MD WCC Insurer Request for Change of Address - print only - Maryland

INSURER REQUEST FOR CHANGE OF ADDRESS
This form is to be used only to change the address of an insurer. Using the form will change the mailing address in all claims that are registered with the Commission at the prior address shown below. You must include both the prior as well as the new address in order to make an address change. Incomplete requests will not be processed. This form may not be used to change an address in an individual claim.

WORKERS' COMPENSATION COMMISSION

Insurance Company Name Federal Employer Identification Number (FEIN) Insurance Company Subsidiaries/FEIN (Please attach additional pages as needed to list more than 10). Subsidiary Name FEIN

NEW ADDRESS:
Street Additional Address (Apt., Suite, etc.) City State ZIP Code

PRIOR ADDRESS:
Street

Additional Address (Apt., Suite, etc.) City State INSURER ZIP Code

Requested by:
Name of Authorized Individual Title

INSURER ATTORNEY

Telephone Number Date

Signature of Authorized Individual (REQUIRED)
Street Address Additional Address (Apt., Suite, etc.) City State

ZIP Code

10 East Baltimore Street Baltimore, Maryland 21202-1641 410-864-5100 Email: [email protected] Web: http://www.wcc.state.md.us WCC H13R (09/12/08)