Insurers Termination Of Temporary Total Disability Benefits
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Insurers Termination Of Temporary Total Disability Benefits Form. This is a Maryland form and can be use in Adjudication Claims Workers Compensation.
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Tags: Insurers Termination Of Temporary Total Disability Benefits, C-06, Maryland Workers Compensation, Adjudication Claims
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
Social Security Number
Claimant
Employer
Insurer
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)
2. There is no medical evidence or documentation to support continuing payment.
3. You failed to keep the medical appointment scheduled for
. (date)
4. You have reached maximum medical improvement.
5.
.
Contact
at (
Insurer Representative
)
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
Date
Name
Telephone Number
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)
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