Free MD WCC Employer Designee H23R - Maryland

REQUEST FOR EMPLOYER DESIGNEE TO RECEIVE NOTICE OF EMPLOYEE CLAIMS
This form is to be used only for employers to designate a person to receive a copy of each Notice of Employee's Claim (C-30) pursuant to Regulation 14.09.01.23(c)(2). Please note that this request will apply to all locations with the identical Employer name, regardless of the address. For special circumstances, please contact the Claims Division.

Name of Employer: Address:

Telephone Number: The above-named employer, pursuant to Regulation 14.09.01.23(c)(2), requests that a copy of each Notice of Employee's Claim (C-30) filed against it be sent to: Name of Designee: Address:

Telephone Number:

Requested By:
Employer

_________________________________________
Authorized Signature Date

Title

Telephone Number

Address

WCC Form H23R (06/15/09)

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