Maryland > Workers Compensation > Adjudication Claims
Application For Lump Sum H-10 - Maryland
| Application For Lump Sum Form. This is a Maryland form and can be used in Adjudication Claims Workers Compensation . |
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WORKERS COMPENSATION COMMISSION APPLICATION FOR LUMP SUM INSTRUCTIONS: This form is to be used ONLY for requesting a lump sum payment from a permanent disability award. CLAIM NUMBER: CLAIMANTS NAME: EMPLOYER: INSURER: AGE MARITAL STATUS # of Dependents Are you working? With/For whom? What are you making per week? Social Security Number How much do you want in a lump sum? Accident/Occupational Disease Date R eason (Complete & detailed explanation) Continue as attachment if needed NOTE: All bills, papers, etc. in support of this request must be attached to th is application before it can be considered for approval by the Commission. Employer/Insurer Consents to the Lump Sum SIF Consents to the Lump Sum Employer/Insurer Objects, Please Set for Hearing SIF Objects, Please Set for Hearing I hereby certify that a copy of this request and its documentation has been sent to opposing counsel/ptaries. REQUESTED BY: Full Name Signature Date of Request CLAIMANT CLAIMANTS ATTY EMPLOYER INSURER/EMPLOYER ATTY OTHER: STREET ADDREESS TELEPHONE CITY STATE ZIP CODE WCC H-10 (Rev. 9/03/03) 10 East Baltimore Street l Baltimore, Maryland 21202-1641 410-864-5100 l Email: info@wcc.state.md.us l Web: http://www.wcc.state.md.us
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