Employer Or Self-Insured Employer Request For Change Of Address {H22R}

WORKERS' COMPENSATION COMMISSION EMPLOYER OR SELF-INSURED EMPLOYER REQUEST FOR CHANGE OF ADDRESS This form is to be used only to change the address of an employer or self-insured employer. Using the form will change the mailing address in all claims that are registered with the Commission at the prior address shown below. You must include both the prior as well as the new address in order to make an address change. Incomplete requests will not be processed. This form may not be used to change an address in an individual claim. Company Name Federal Employer Identification Number (FEIN) NEW ADDRESS Street Additional Info (Apt., Suite, etc.) City State ZIP Code PRIOR ADDRESS Street Additional Info (Apt., Suite, etc.) City State ZIP Code REQUESTED BY: Employer Self-Insured Employer Employer/Self-Insured Employer Attorney Name of Authorized Individual Title Telephone Number Signature of Authorized Individual (REQUIRED) Street Address City State Date ZIP Code 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 H22R (09/12/08) American LegalNet, Inc. www.FormsWorkFlow.com