Maryland > Workers Compensation > Adjudication Claims
Attorney Registration Or Information Change Form - Maryland
|Attorney Registration Or Information Change Form Form. This is a Maryland form and can be used in Adjudication Claims Workers Compensation .||
|Get this form for FREE as a print-only pdf|
DATE STAMP WORKERS COMPENSATION COMMISSION 10 East Baltimore Street BALTIMORE, MD 21202-1641 BALTIMORE PHONE 410-864-5100 TOLL FREE 1-800-492-0479 IN MARYLAND BALTIMORE TTD FOR Hearing Impaired 410-383-7555 ATTORNEY REGISTRATION or INFORMATION CHANGE FORM There is no fee to change contact information for an attorney whose regi stration is current (changed/updated since 9/2000). Registration processing fee is $25.00 and must be included with this for m. Check or money order only payable to "Workers Compensation Commission." This registers an attorney to practice before the WCC. A current registration is a requirement for WCC Online Services (WFMS) . This form is not a WFMS application. Form Revised 4/06/04 1. First Name 2. Mid dleInitial 3. Last Name 4. Address 5. Additional Address Info: Suite/Bldg. 6. City 7. State 8. Zip C ode 9. Telephone Number 10. E-Mail Address (e.g. email@example.com) Attorney Code (REQUIRED) NOTE: This form CANNOT be handwritten, it MUST completed in Adobe Reader when an electronic form or typed. Handwritten, illegible or incomplete (without payment) form s are returned without processing.