Free Employer or Sef-Insured Employer Request for Change of Address - Maryland

WORKERS' COMPENSATION COMMISSION

EMPLOYER OR SELF-INSURED EMPLOYER REQUEST FOR CHANGE OF ADDRESS
This form is to be used only to change the address of an employer or self-insured employer. 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.

Company Name Federal Employer Identification Number (FEIN) 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:
Employer Self-Insured Employer Employer/Self-Insured Employer Attorney

Name of Authorized Individual Title Telephone Number

Signature of Authorized Individual (REQUIRED) Street Address City State

Date

ZIP Code

10 East Baltimore Street Baltimore, Maryland 21202-1641 410-864-5100 Email: [email protected] Web: http://www.wcc.state.md.us WCC H22R (09/12/08)