Maryland > Workers Compensation > Adjudication Claims
Claimant Request For Change Of Address H31R - Maryland
| Claimant Request For Change Of Address Form. This is a Maryland form and can be used in Adjudication Claims Workers Compensation . |
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WORKERS COMPENSATION COMMISSION CLAIMANT REQUEST FOR C HANGE OF ADDRESS This form is to be used only to change the address of a claimant. Attorneys must use the WCC Attorney Registration Form to change any cont act information. WCC CLAIM NUMBER: CLAIMA NT: EMPLOYER: INSURE R: NEW ADDRESS Street Additional Info (Apt., Suite, etc.) City Sta te Zip Code PRIOR ADDRESS Street Additional Info (Apt., Suite, etc.) City State Zip Code REQUESTED BY: CLAIMANT CLAIMANTS ATTORNEY FULL NAME Street Address City State Zi p Code A copy of this form has been sent to the other parties/attorneys to this action. __________________________________ SIGNATURE DATE TELEPHONE NUMBER 10 East Baltimore Street l Baltimore, Maryland 21202-1641 W CC H31R (03/22/04) 410-864-5100 l Email: info@wcc.state.md.us l Web: http://www.wcc.state.md.us
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