Maryland > Workers Compensation > Adjudication Claims
Stipulation Of Parties And Award Of Compensation H-34 - Maryland
| Stipulation Of Parties And Award Of Compensation Form. This is a Maryland form and can be used in Adjudication Claims Workers Compensation . |
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STIPULATION OF PARTIES AND AWARD OF COMPENSATIONWORKERS COMPENSATION COMMISSION 10 East Baltimore Street l Baltimore, Maryland 21202-1641 WCC Claim #: 410-864-5100 l Email: info@wcc.state.md.us Claimant: Web: http://www.wcc.state.md.us Claimant SS #: Employer: Insurer: It is STIPULATED this day of 2000 by and be,tween EMPLOYEE, and EMPLOYER, ,and INSURER, that, an Award of Compensation is necessary and appropriate in the above-titled claim based on the following information: (1) Date of Accident: [Amended: Y N ] (2) Employees Average Weekly Wage: [Amended: Y N ] (3) Temporary Total / Temporary Partial: (4) Attached hereto are the medical evaluation report(s) of: Claimants Doctor #1 #2 Insurers Docto r#1 #2 (5) The Parties agree to a permanent partial disability of : at the rate of $ payab,le weekly, beginning for weeks. IN WITNESS WHEREOF, the Parties hereto have duly executed the aforementioned statements on the day and year as stated above. ATTEST: Signature of Attorney for Claimant Signature of Claimant , EMPLOYER and INSURER B Y: Signature for Employer/Insurer Page 1 of 2 Pages WCC H-34 (Rev 9/05/03) <<<<<<<<<********>>>>>>>>>>>>> 2 STIPULATION OF PARTIES AND AWARD OF COMPENSATION Page 2 of 2 Pages ???? The Employee being unrepresented by Counsel, the Insurer furnishes herewith copies of all medical reports in its possession. ???? The undersigned, as Employee in the above-entitled case and not being represented by Counsel, does hereby state that I understand that this Stipulation does not foreclose my future right to reopen my case and the right to continuing medical care; that I have the right to have any future claim heard before the Workers Compensation Commission; and that I would have a right to appeal any decision in the future to be made by the Workers Compensation Commission; and that I have entered into this Stipulation only for the purpose of determining the degree of my disability at this time. WITNESS:____________________________ CLIAMANT: ____________________________ Signature Signature * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * (6) COUNSEL AND MEDICAL FEES: Counsel for Claimant in this case requests that from the final weeks of compensation the following fees shall be paid: CONSENT OF CLAIMANT: The Claimant in this case has read and signed the Stipulation and consents to the fees as set forth above. Signature of Claimant * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * of 2 Pages Page 2 WCC H-34 (Rev 9/05/03)
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