Employer Or Insurer Request For Change Of Address
Download Free Print-Only PDF OR Purchase Interactive PDF Version of this Form
Employer Or Insurer Request For Change Of Address Form. This is a Maryland form and can be use in Adjudication Claims Workers Compensation.
Tags: Employer Or Insurer Request For Change Of Address, H22R, Maryland Workers Compensation, Adjudication Claims
WORKERS' COMPENSATION COMMISSION
EMPLOYER/INSURER REQUEST FOR CHANGE OF ADDRESS
This form is to be used only to change the address of an employer, insurer or self-insured employer.
Attorneys must use the WCC Attorney Registration Form to change any contact 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
State
Zip Code
REQUESTED BY:
EMPLOYER
INSURER
SELF-INSURED EMPLOYER
Name of Authorized Individual
Street Address
Title
City
EMPLOYER/INSURER ATTORNEY
State
Zip Code
__________________________________
Signature of Authorized Individual (Required)
WCC H22R (03/22/04)
Date
Telephone Number
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
