WORKERS' COMPENSATION COMMISSION CLAIMANT REQUEST FOR CHANGE OF ADDRESS This form can be used only to change the Claimant Address for the Claim Number indicated and cannot be used for other parties in the claim. No filing accepted by email or FAX. WCC CLAIM NUMBER: CLAIMANT: EMPLOYER: INSURER: NEW ADDRESS Street City State Zip Code PRIOR ADDRESS Street City State Zip Code REQUESTED BY: CLAIMANT CLAIMANT'S ATTORNEY FULL NAME Street Address City State Zip Code I hereby certify that on the day of , a copy of this Request has been sent to the Workers' Compensaton Commission, all parties and their attorneys. __________________________________ Signature Date Telephone Number WCC H31R (01/2016) 10 East Baltimore Street q Baltimore, Maryland 21202-1641 410-864-5100 q Email: info@wcc.state.md.us qWeb: http://www.wcc.state.md.us American LegalNet, Inc. www.FormsWorkFlow.com