Maryland > Workers Compensation > Adjudication Claims
Employer Or Insurer Request For Change Of Address H22R - Maryland
| Employer Or Insurer 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 EMPLOYER/INSURER REQUEST FOR CHANGE OF ADDRESS This form is to be used only to change the address of an employer, insur er or self-insured employer. Attorneys must use the WCC Attorney Registration Form to change any cont act information. The undersigned party hereby requests that a change of address be recorded for: EMPLOYER INSURER SELF-INSURED EMPLOYER COMPANY NAME NEW ADDRESS Street Additional Info (Apt., Suite, etc.) City State Zip Code PRIOR ADDRESS Street Additional Info (Apt., Suite, etc.) City St ate Zip Code REQUESTED BY: EMPLOYER INSURER SELF-INSURED EMPLOYER EMPLOYER/INSURER ATTORNEY Name of Authorized Individual Street Address Title City State Zip Code __________________________________ Signature of Authorized Individual (Required) Date Telephone Number 10 East Baltimore Street l Baltimore, Maryland 21202-1641 WCC H22R (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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