Get Md Wcc Uef Claimant Questionnaire. Claimant Questionnaire Version 8/15/07

This guide offers clear and concise instructions on how to complete the MD WCC UEF Claimant Questionnaire online. By following these steps, users can provide necessary information accurately and expedite the claims process.

Follow the steps to fill out the MD WCC UEF Claimant Questionnaire online.

1. Press the ‘Get Form’ button to access the form and open it in your preferred online editor.
2. Begin by filling in your full name, address, telephone number, social security number, and date of birth in the designated fields.
3. Provide your employer's full name, address, and telephone number during the time of your injury.
4. If applicable, list any other companies involved at the worksite during your injury, including their names, addresses, and telephone numbers, along with the accident's location.
5. Specify the exact location of the accident.
6. Detail your job title, duties, who hired you, your hire date, and whether you signed any contracts (if yes, attach a copy). Include the name of your foreman or supervisor.
7. Answer questions regarding your work hours. Indicate if you were paid by the job or hourly, the method of payment (check or cash), and if taxes and social security were withheld.
8. State your weekly earnings at the time of the injury and confirm if tax returns were filed for the year of and the year prior to your injury. Attach relevant pay stubs or tax returns if available.
9. Describe the details of your accident, including the date, time, place, and the parts of your body that were injured.
10. List all witnesses to your accident, along with their addresses and phone numbers.
11. Mention everyone with whom you discussed your accident and injuries.
12. Provide contact details for individuals who may have personal knowledge of the accident or injuries.
13. If a vehicle was involved, give details about the vehicle ownership, any leases, and whether a police report was filed (attach a copy if available).
14. Disclose any substance intake in the 48 hours before your injury, including the names and times of consumption.
15. List all medical providers who treated you for your injury and attach relevant medical records.
16. Identify any payments made by your employer or health insurance for treatment or disability benefits.
17. Document dates of work absence due to injury and provide details about any work performed since the injury.
18. Indicate if you have applied for unemployment benefits, including relevant dates and claim numbers.
19. Mention any prior accidents or injuries that could affect your claim, providing details and medical contacts if applicable.
20. If applicable, state any previous claims or lawsuits related to injuries and their outcomes.
21. If claiming an occupational disease, provide details of your disability dates, treatment, notice given to employer, exposure details, and related medical documentation.
22. Certify the accuracy of your information by signing the form.
23. Once completed, save your changes, print, or share the form as needed.

Complete your MD WCC UEF Claimant Questionnaire online to ensure your claim is processed efficiently.