Request For Employer Designee To Receive Notice Of Employee Claims {H23R}

WORKERS COMPENS ATION COMMISS ION 10 EAST BALTIMORE STREET BALTIMORE, MD 21202-1641 REQUEST FOR EMPLOYER DESIGNEE TO RECEIVE NOTICE OF EMPLOYEE CLAIMS This form is to be used only for employers to designate a person to receiopy ove a cf each Notice of Employees Claim (C-30) pursuant to Regulation 14.09.01.23(c)(2)P.l ease 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. Please type or print legibly. Name of Employer: Address: Telephone Number: The above-named employer, pursuant to Regulation 14.09.01.23(c)(2), requests that a coeachpy of Notice of Employees Claim (C-30) filed against it be sent to: Name of Designee: Address: Telephone Number: Requested By: E mployer Authorized Signature Date Title T elephone Numbe r Address WCC Form H23R (11/26/02) 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