WCC Form H-05 "Claimant's Affidavit in Support of Settlement" - Maryland

What Is WCC Form H-05?

This is a legal form that was released by the Maryland Workers' Compensation Commission - a government authority operating within Maryland. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 1, 2009;
  • The latest edition provided by the Maryland Workers' Compensation Commission;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of WCC Form H-05 by clicking the link below or browse more documents and templates provided by the Maryland Workers' Compensation Commission.

ADVERTISEMENT
ADVERTISEMENT

Download WCC Form H-05 "Claimant's Affidavit in Support of Settlement" - Maryland

1181 times
Rate (4.8 / 5) 59 votes
WORKERS' COMPENSATION COMMISSION
CLAIMANT’S AFFIDAVIT IN SUPPORT OF SETTLEMENT
I,
, am the claimant in claim #
.
I ask the Workers’ Compensation Commission to approve the settlement of my claim and in
support of this request state:
1. I am over eighteen (18) years of age and am competent to testify.
2. I am voluntarily settling my claim.
3. I acknowledge that in settling my claim, I am giving up the following rights:
a. the right to hearings before the Workers’ Compensation Commission for resolution of any
disputes regarding my claim;
b. the right to vocational rehabilitation services and to payment during my lifetime for any
medical treatment related to my claim, except as provided, if at all, in this settlement;
c. the right, except as provided, if at all, in this settlement, to be compensated, under certain
conditions, by the Subsequent Injury Fund for permanent impairments incurred before the
accidental injury or occupational disease which gave rise to my claim;
d. the right to ask the Workers’ Compensation Commission, within 5 years of the last
payment of any compensation that it might have ordered, to reopen my claim should my
condition related to my claim worsen;
e. the right to appeal to the appropriate Circuit Court if I am dissatisfied with a decision of
the Workers’ Compensation Commission;
f. the right to appeal to the Court of Special Appeals if I am dissatisfied with the decision of
the Circuit Court; and
g. the right to petition the Court of Appeals to review the decision of the Court of Special
Appeals if I am dissatisfied with the decision of the Court of Special Appeals; and
4. that, by signing this affidavit, I acknowledge that I have read, and understand, the terms of this
settlement and all the documents attached in support of it, including medical reports and this
affidavit.
I solemnly affirm under the penalties of perjury and upon personal knowledge that the contents
of the foregoing affidavit are true and accurate.
I, as attorney for the claimant, have reviewed
this affidavit with the claimant.
Claimant’s Signature
Attorney for Claimant Signature
Claimant’s Name (printed)
Attorney for Claimant Name (printed)
Date
Date
10 East Baltimore Street Baltimore, Maryland 21202-1641
410-864-5100 Email: info@wcc.state.md.us Web: http://www.wcc.state.md.us
MD WCC Form H-05 12/2009
CLICK HERE TO CLEAR THE FORM
WORKERS' COMPENSATION COMMISSION
CLAIMANT’S AFFIDAVIT IN SUPPORT OF SETTLEMENT
I,
, am the claimant in claim #
.
I ask the Workers’ Compensation Commission to approve the settlement of my claim and in
support of this request state:
1. I am over eighteen (18) years of age and am competent to testify.
2. I am voluntarily settling my claim.
3. I acknowledge that in settling my claim, I am giving up the following rights:
a. the right to hearings before the Workers’ Compensation Commission for resolution of any
disputes regarding my claim;
b. the right to vocational rehabilitation services and to payment during my lifetime for any
medical treatment related to my claim, except as provided, if at all, in this settlement;
c. the right, except as provided, if at all, in this settlement, to be compensated, under certain
conditions, by the Subsequent Injury Fund for permanent impairments incurred before the
accidental injury or occupational disease which gave rise to my claim;
d. the right to ask the Workers’ Compensation Commission, within 5 years of the last
payment of any compensation that it might have ordered, to reopen my claim should my
condition related to my claim worsen;
e. the right to appeal to the appropriate Circuit Court if I am dissatisfied with a decision of
the Workers’ Compensation Commission;
f. the right to appeal to the Court of Special Appeals if I am dissatisfied with the decision of
the Circuit Court; and
g. the right to petition the Court of Appeals to review the decision of the Court of Special
Appeals if I am dissatisfied with the decision of the Court of Special Appeals; and
4. that, by signing this affidavit, I acknowledge that I have read, and understand, the terms of this
settlement and all the documents attached in support of it, including medical reports and this
affidavit.
I solemnly affirm under the penalties of perjury and upon personal knowledge that the contents
of the foregoing affidavit are true and accurate.
I, as attorney for the claimant, have reviewed
this affidavit with the claimant.
Claimant’s Signature
Attorney for Claimant Signature
Claimant’s Name (printed)
Attorney for Claimant Name (printed)
Date
Date
10 East Baltimore Street Baltimore, Maryland 21202-1641
410-864-5100 Email: info@wcc.state.md.us Web: http://www.wcc.state.md.us
MD WCC Form H-05 12/2009
CLICK HERE TO CLEAR THE FORM