WCC Form H23R "Request for Employer Designee to Receive Notice of Employee Claims" - Maryland

What Is WCC Form H23R?

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 June 15, 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 H23R 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 H23R "Request for Employer Designee to Receive Notice of Employee Claims" - Maryland

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REQUEST FOR EMPLOYER DESIGNEE TO RECEIVE NOTICE
OF EMPLOYEE CLAIMS
This form is to be used only for employers to designate a person to receive a copy of each Notice of Employee’s Claim
(C-30) pursuant to Regulation 14.09.01.23(c)(2). Please note that this request will apply to all locations with the
identical Employer name, regardless of the address. For special circumstances, please contact the Claims Division.
Name of Employer:
Address:
Telephone Number:
The above-named employer, pursuant to Regulation 14.09.01.23(c)(2), requests that a copy of each
Notice of Employee’s Claim (C-30) filed against it be sent to:
Name of Designee:
Address:
Telephone Number:
Requested By:
Employer
_________________________________________
Authorized Signature
Date
Title
Telephone Number
Address
Click to Clear the Form
WCC Form H23R (06/15/09)
WORKERS’ COMPENSATION COMMISSION 10 East Baltimore Street Baltimore Maryland 21202-1641
(410) 864-5100 Email: info@wcc.state.md.us Web: http://www.wcc.state.md.us
REQUEST FOR EMPLOYER DESIGNEE TO RECEIVE NOTICE
OF EMPLOYEE CLAIMS
This form is to be used only for employers to designate a person to receive a copy of each Notice of Employee’s Claim
(C-30) pursuant to Regulation 14.09.01.23(c)(2). Please note that this request will apply to all locations with the
identical Employer name, regardless of the address. For special circumstances, please contact the Claims Division.
Name of Employer:
Address:
Telephone Number:
The above-named employer, pursuant to Regulation 14.09.01.23(c)(2), requests that a copy of each
Notice of Employee’s Claim (C-30) filed against it be sent to:
Name of Designee:
Address:
Telephone Number:
Requested By:
Employer
_________________________________________
Authorized Signature
Date
Title
Telephone Number
Address
Click to Clear the Form
WCC Form H23R (06/15/09)
WORKERS’ COMPENSATION COMMISSION 10 East Baltimore Street Baltimore Maryland 21202-1641
(410) 864-5100 Email: info@wcc.state.md.us Web: http://www.wcc.state.md.us