WORKERS' COMPENSATION COMMISSION
CLAIMANT REQUEST FOR CHANGE OF ADDRESS
This form is to be used only to change the address of a claimant. Attorneys must use the WCC Attorney Registration Form to change any contact information.
WCC CLAIM NUMBER: CLAIMANT: EMPLOYER: INSURER: 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:
CLAIMANT
CLAIMANT'S ATTORNEY
FULL NAME
Street Address City State Zip Code
A copy of this form has been sent to the other parties/attorneys to this action.
__________________________________
SIGNATURE
DATE
TELEPHONE NUMBER
CLICK HERE TO CLEAR THE FORM
WCC H31R (03/22/04)
10 East Baltimore Street q Baltimore, Maryland 21202-1641 410-864-5100 q Email: [email protected] qWeb: http://www.wcc.state.md.us