Maryland > Workers Compensation > Adjudication Claims
Insurers Termination Of Temporary Total Disability Benefits C-06 - Maryland
| Insurers Termination Of Temporary Total Disability Benefits 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 |
|||||||
|
WORKERS' COMPENSATION COMMISSION INSURER'S TERMINATION OF TEMPORARY TOTAL DISABILITY BENEFITS Pursuant to LE ยง9-733(b), Annotated Code of Maryland, this form must be sent to the claimant. A copy must also be sent to the Workers' Compensation Commission and claimant's attorney. WCC Claim Number Claimant Employer Insurer Social Security Number This is your last temporary total disability compensation check/payment and includes (date). benefits through: The insurer/employer has terminated your payments for the following reason(s): 1. You returned to work on . (date) . (date) 2. There is no medical evidence or documentation to support continuing payment. 3. You failed to keep the medical appointment scheduled for 4. You have reached maximum medical improvement. 5. Contact Insurer Representative . at ( ) Telephone for further information if desired. After contacting the insurance representative, if you are in disagreement or are dissatisfied, you have the right to request a hearing before the Workers' Compensation Commission. Please include a copy of this form with your request for a hearing on the MD WCC "Issues" form (H24R) selecting the appropriate Temporary Total Disability issue (#13 or #17). INSURER CERTIFICATION OF SERVICE I hereby certify that a copy of this form has been filed with the Workers' Compensation Commission and sent to all parties and/or their attorneys. Signature Name Telephone Number Date 10 East Baltimore Street Baltimore, Maryland 21202-1641 410-864-5100 Email: info@wcc.state.md.us Web: http://www.wcc.state.md.us WCC Form C-06 (02/15/07) American LegalNet, Inc. www.FormsWorkflow.com
|
|||||||
