WCC Form H13R "Insurer Request for Change of Address" - Maryland

What Is WCC Form H13R?

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 September 12, 2008;
  • 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 H13R by clicking the link below or browse more documents and templates provided by the Maryland Workers' Compensation Commission.

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Download WCC Form H13R "Insurer Request for Change of Address" - Maryland

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W O R K E R S ' C O M P E N S A T I O N C O M M I S S I O N
INSURER REQUEST FOR CHANGE OF ADDRESS
This form is to be used only to change the address of an insurer. Using the form will change the mailing address in
all claims that are registered with the Commission at the prior address shown below. You must include both the
prior as well as the new address in order to make an address change. Incomplete requests will not be processed.
This form may not be used to change an address in an individual claim.
Insurance Company Name
Federal Employer Identification Number (FEIN)
Insurance Company Subsidiaries/FEIN
(Please attach additional pages as needed to list more than 10).
Subsidiary Name
FEIN
NEW ADDRESS:
Street
Additional Address
(Apt., Suite, etc.)
City
State
ZIP Code
PRIOR ADDRESS:
S treet
Additional Address
(Apt., Suite, etc.)
City
State
ZIP Code
Requested by:
INSURER
INSURER ATTORNEY
Name of Authorized Individual
Title
Telephone Number
Date
Signature of Authorized Individual
(REQUIRED)
Street Address
Additional Address
(Apt., Suite, etc.)
City
State
ZIP Code
10 East Baltimore Street
Baltimore, Maryland 21202-1641
410-864-5100
Email: info@wcc.state.md.us Web: http://www.wcc.state.md.us
Reset This Form
WCC H13R (09/12/08)
W O R K E R S ' C O M P E N S A T I O N C O M M I S S I O N
INSURER REQUEST FOR CHANGE OF ADDRESS
This form is to be used only to change the address of an insurer. Using the form will change the mailing address in
all claims that are registered with the Commission at the prior address shown below. You must include both the
prior as well as the new address in order to make an address change. Incomplete requests will not be processed.
This form may not be used to change an address in an individual claim.
Insurance Company Name
Federal Employer Identification Number (FEIN)
Insurance Company Subsidiaries/FEIN
(Please attach additional pages as needed to list more than 10).
Subsidiary Name
FEIN
NEW ADDRESS:
Street
Additional Address
(Apt., Suite, etc.)
City
State
ZIP Code
PRIOR ADDRESS:
S treet
Additional Address
(Apt., Suite, etc.)
City
State
ZIP Code
Requested by:
INSURER
INSURER ATTORNEY
Name of Authorized Individual
Title
Telephone Number
Date
Signature of Authorized Individual
(REQUIRED)
Street Address
Additional Address
(Apt., Suite, etc.)
City
State
ZIP Code
10 East Baltimore Street
Baltimore, Maryland 21202-1641
410-864-5100
Email: info@wcc.state.md.us Web: http://www.wcc.state.md.us
Reset This Form
WCC H13R (09/12/08)